Volunteer Driver Program Application

1. Name
2. Street Address
3. Town/City
4. Zip
5. Mailing Address
6. Mailing Town/City
7. Mailing Zip
8. Home Phone Number
9. Cell Phone Number
10. Beeper
11. How long have you been a resident of Vermont?
12. Valid Vermont Driver’s License Number

1. Have you been in an automobile accident in the past 3 years?
2. Have you been cited for a traffic violation in the past 3 years?
3. Have you ever been accused or convicted of a crime?
4. Have you ever been interviewed or investigated by the Department for Children and Families (DCF) family services division or the police for child abuse, senior abuse and/or neglect?

All ride assignments are optional—tell us how much or how little you want to volunteer.

1. Are you comfortable driving in winter snow conditions?
2. Are you able to drive during dusk/dawn and night hours?
3. Are you able to assist a passenger to and from the vehicle?
4. Are you able to assist a passenger with a wheelchair or a walker?
5. Are you willing to travel long distance, such as Burlington, Hanover NH And St. Johnsbury?

1. Please briefly describe why you wish to volunteer as a community rides driver:
2. How did you learn about the community rides volunteer driver program?
3. If you are 55 yrs. Of age or older, you are eligible for RSVP (retired and senior volunteer program) membership which may offer additional insurance options. Are you currently a member?
4. If no, are you interested in becoming a rsvp member?

Reference 1

1. Name
2. Day Phone Number
3. Mailing Address

Reference 2

1. Name
2. Day Phone Number
3. Mailing Address

Reference 3

1. Name
2. Day Phone Number
3. Mailing Address

To become a volunteer driver, you will need to provide a valid driver’s license, up-to-date auto insurance (with a good driving record), and complete a full background check. Your transportation agency will contact you for this information upon processing your initial application.

For the safety and well being of all transportation agency clients and staff, we require that all potential community volunteer drivers agree to the following:

I hereby grant my transit agency the permission to contact the references I have given below, and also grant such references permission to speak truthfully and in detail about me.

I hereby grant my transit agency permission to investigate my personal history through any investigative agencies or bureaus of their choice in order to obtain verification in the following:

• Adult abuse registry
• Child abuse registry
• Vermont criminal record check
• National criminal record check
• motor vehicle inspection
• driver license check

I understand that this online form submits by e-mail and that data is transmitted unencrypted. This exposes some risk to this data being intercepted and read by 3rd parties.

I have read and agree to these terms and conditions.

1. Do not type here