Phone number *
Phone type Mobile Home Work Other
Car #1 Insurance Company *
Company Name
Car #1 Amount of liability of insurance per person for bodily injury *
The church requires volunteer drivers to have a minimum amount of $100,000 liability per person for bodily injury.
Car #1 Amount of liability per incident for bodily injury for all vehicle occupants *
The church requires volunteer drivers to have a minimum amount of $300,000 liability per incident for bodily injury to all vehicle occupants.
Car #1 Amount of liability for property damage *
The church requires volunteer drivers to have a minimum amount of $50,000 - $100,000 liability for property damage.
Do you have Uninsured/underinsured motorist coverage? *
I would like to add a second car *
Do you have any physical condition or are taking any medication which would affect driving safety? *
Have you been in an accident in the last three years? *
Have you been ticketed for a moving violation within the last three years? *
Have you been convicted for WDWI/DUI, or had your license suspended for a moving violation, hit and run, eluding an officer, reckless or negligent operation of a vehicle, or driving while under suspension or revocation within the last five years? *
Please attach a copy of your driver’s license *
Choose 1 file. Maximum file size 10 MB.
Please attach a copy of your car insurance card *
Choose 1 file. Maximum file size 10 MB.
Students riding in my vehicle(s) will be seated and secured with an individual working seatbelt for each seat. No double seating of children is permitted. State law requires me to have a child restraint seat for each child under the age of eight or shorter than 4'8". All children aged 12 and under will be seated in the back seat.
Declaration - Please add your full name as your digital signature *
I affirm that I will carefully transport minor participants under my care and obey all traffic laws. I also declare that by signing this driver form, I will not have ingested alcohol, a controlled substance, or any other medication that impairs my driving abilities during or within six (6) hours before the event or activity.
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