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ϮϬϭϬsŽůƵŶƚĞĞƌĂƉƉůŝĐĂƟŽŶĨŽƌŵ Volunteer  No.  :  

VOLUNTEER IDENTIFICATION  Civic  number  

 Last  name

 Surname  at  birth

 Street  

 Telephone  (home)  

 Apt.  

 Telephone  (cell)  

 First  name  

 Middle  name

F

 Extension  Date  of  birth  (YYYY/MM/DD)  Expiry  date  (YYYY/MM/DD)

 Driver’s  Licence  No.  (File  No.)  

Email

 Manual  transmission Yes No

'ƌŽƵƉͬŽŵƉĂŶLJŽƌŐĂŶŝnjŝŶŐLJŽƵƌĞǀĞŶŝŶŐǁŝƚŚKƉĞƌĂƟŽŶZĞĚEŽƐĞ͕ŝĨĂƉƉůŝĐĂďůĞ

 Name  of  your  insurance  company  (mandatory  for  escort  drivers)

M

 Postal  code  

 City  

 Telephone  (work)  

   Sex  

 Policy  No.

 Expiry  date  (YYYY/MM/DD)

DECLARATION /ŚĞƌĞďLJǀŽůƵŶƚĞĞƌŵLJƐĞƌǀŝĐĞƐĨŽƌƚŚŝƐLJĞĂƌ͛ƐĐĂŵƉĂŝŐŶ͘/ĂƵƚŚŽƌŝnjĞĂŶLJƉŽůŝĐĞƐĞƌǀŝĐĞǁŝƚŚũƵƌŝƐĚŝĐƟŽŶŽǀĞƌĂŶLJŽƌĂůůƉĂƌƚƐŽĨƚŚĞƉƌŽǀŝŶĐĞŝŶǁŚŝĐŚ/ƌĞƐŝĚĞƚŽĐŽŶĚƵĐƚĂďĂĐŬ-­‐ ŐƌŽƵŶĚĐŚĞĐŬĨŽƌĂŶLJĂƌƌĞƐƚ͕ĐŚĂƌŐĞŽƌĐŽŶǀŝĐƟŽŶĨŽƌĂĐƌŝŵŝŶĂůŽīĞŶĐĞĨŽƌǁŚŝĐŚ/ŚĂǀĞŶŽƚƌĞĐĞŝǀĞĚƌĞŚĂďŝůŝƚĂƟŽŶŽƌĂƉĂƌĚŽŶ͕ĂŶĚĨŽƌĂŶLJƉĞŶĂůŽīĞŶĐĞ͘/ĂůƐŽĂƵƚŚŽƌŝnjĞĂůůƉŽůŝĐĞ services  to  verify  the  validity  of  my  driver’s  licence.    /ĂƵƚŚŽƌŝnjĞĂůůƉŽůŝĐĞƐĞƌǀŝĐĞƐƚŽĐŽŶĚƵĐƚƚŚĞƐĂŝĚďĂĐŬŐƌŽƵŶĚĐŚĞĐŬƚŽĞŶƐƵƌĞƚŚĂƚ/ŵĞĞƚƚŚĞKƉĞƌĂƟŽŶZĞĚEŽƐĞƐĞůĞĐƟŽŶĐƌŝƚĞƌŝĂ͕ĂƐƐĞƚŽƵƚďĞůŽǁ͗

^ĞůĞĐƟŽŶƌŝƚĞƌŝĂ  /ŶĐŽŵƉĂƟďůĞŽīĞŶĐĞƐŝĨĐŽŵŵŝƩĞĚ  Sex  :  ƉƌŽƐƟƚƵƟŽŶ;ƐŽůŝĐŝƚĂƟŽŶͿ ǁŝƚŚŝŶƚŚĞůĂƐƚĮǀĞLJĞĂƌƐ

/ŶĐŽŵƉĂƟďůĞŽīĞŶĐĞƐĂƚĂůůƟŵĞƐ

KīĞŶĐĞƐƌĞƐƵůƟŶŐŝŶůŝŵŝƚĞĚ acceptance

dŚĞŌ͕ĨƌĂƵĚ͗/ŵƉĞƌƐŽŶĂƟŽŶ  Violence  :  ĂƐƐĂƵůƚ͕ƚƌĞƐƉĂƐƐŝŶŐĂƚŶŝŐŚƚ͕ƵƩĞƌŝŶŐƚŚƌĞĂƚƐ͕ŝŶƟŵŝĚĂƟŽŶ͕  Drugs  :  possession ŚĂƌĂƐƐŵĞŶƚ͕ŝŶĚĞĐĞŶƚƚĞůĞƉŚŽŶĞĐĂůůƐ͕ŵŝƐĐŚŝĞĨ͕ĂƌƐŽŶĐĂƵƐŝŶŐĚĂŵĂŐĞ  Other  :ďƌĞĂĐŚŽĨĐŽŶĚŝƟŽŶŽƌƉƌŽďĂƟŽŶ͕ŽďƐƚƌƵĐƟŶŐĂƉĞĂĐĞŽĸĐĞƌ͕ ƚŽƉƌŽƉĞƌƚLJ͕ĮƌĞĂƌŵƐ;ƉŽƐƐĞƐƐŝŽŶ͕ŽŵŝƐƐŝŽŶͿ other  criminal  charges  Sex  :  ƐĞdžƵĂůĂƐƐĂƵůƚŽƌĂƐƐĂƵůƚǁŝƚŚĂǁĞĂƉŽŶ͕ŝŶĚĞĐĞŶƚĂĐƚƐ͕ dŚĞŌ͕ĨƌĂƵĚ͗ďƌĞĂŬŝŶŐĂŶĚĞŶƚĞƌŝŶŐ͕ƌŽďďĞƌLJ͕ĐŽƌƌƵƉƟŽŶ ƉƌŽĐƵƌŝŶŐ͕ĐŚŝůĚƉŽƌŶŽŐƌĂƉŚLJ͕ĐŽƌƌƵƉƟŶŐĐŚŝůĚƌĞŶ͕ďĂǁĚLJŚŽƵƐĞ͕ƌĂƉĞ      Driving  :  ŽīĞŶĐĞĐĂƵƐŝŶŐĚĞĂƚŚŽƌďŽĚŝůLJŚĂƌŵ  Violence  :  ŬŝĚŶĂƉƉŝŶŐ͕ĂƩĞŵƉƚĞĚŵƵƌĚĞƌ͕ŚŽŵŝĐŝĚĞ͕ĂŐŐƌĂǀĂƚĞĚ  Drugs  :  ƚƌĂĸĐŬŝŶŐ͕ŝŵƉŽƌƟŶŐ͕ĐƵůƟǀĂƟŶŐ ĂƐƐĂƵůƚ͕ĐŽŶĮŶĞŵĞŶƚ͕ĞdžƚŽƌƟŽŶ͕ĂƌƐŽŶǁŝƚŚĚŝƐƌĞŐĂƌĚĨŽƌŚƵŵĂŶůŝĨĞ͕  Other  :  arrest  warrant ĮƌĞĂƌŵƐ;ƵŶĂƵƚŚŽƌŝnjĞĚƵƐĞ͕ƚƌĂĸĐŬŝŶŐͿ  Driving  :  ŇŝŐŚƚ͕ĚĂŶŐĞƌŽƵƐŽƉĞƌĂƟŽŶŽĨĂŵŽƚŽƌǀĞŚŝĐƵůĞ͕ƌĞĨƵƐĂůƚŽ dŚĞŌ͕ĨƌĂƵĚ͗dŚĞŌ͕ĨƌĂƵĚ;ĂĐĐĞƉƚĞĚĂƐĂŶĞƐĐŽƌƚĚƌŝǀĞƌĚƵƌŝŶŐƐĂŶĐƟŽŶͿ ĐŽŵƉůLJǁŝƚŚĚĞŵĂŶĚ͕ŽƉĞƌĂƟŽŶǁŚŝůĞŝŵƉĂŝƌĞĚ;ĂĐĐĞƉƚĞĚĂƐĂ ŶĂǀŝŐĂƚŽƌĚƵƌŝŶŐƉƌŽŚŝďŝƟŽŶͿ͕ƵŶƉĂŝĚƟĐŬĞƚƐ;ƟĐŬĞƚƐŵƵƐƚďĞƉĂŝĚ before  volunteering)  

/ĂůƐŽĂƵƚŚŽƌŝnjĞĂůůƉŽůŝĐĞƐĞƌǀŝĐĞƐǁŝƚŚũƵƌŝƐĚŝĐƟŽŶŽǀĞƌĂŶLJŽƌĂůůƉĂƌƚƐŽĨƚŚĞƉƌŽǀŝŶĐĞŝŶǁŚŝĐŚ/ƌĞƐŝĚĞƚŽĨŽƌǁĂƌĚƚŚĞƌĞƐƵůƚƐŽĨƚŚĞďĂĐŬŐƌŽƵŶĚĐŚĞĐŬƐƚŽƚŚĞ KƉĞƌĂƟŽŶZĞĚEŽƐĞĐŽŽƌĚŝŶĂƚŽƌ͘/ŶĂĐĐŽƌĚĂŶĐĞǁŝƚŚƚŚĞƌĞůĞǀĂŶƚůĞŐŝƐůĂƟŽŶ͕/ĂŐƌĞĞƚŽƉƌŽƚĞĐƚƚŚĞĐŽŶĮĚĞŶƟĂůŝƚLJŽĨĂůůŝŶĨŽƌŵĂƟŽŶĂŶĚĚĂƚĂĚŝƐĐůŽƐĞĚƚŽŵĞ ĂďŽƵƚKƉĞƌĂƟŽŶZĞĚEŽƐĞĐůŝĞŶƚƐĂŶĚǀŽůƵŶƚĞĞƌƐ͘                                                                              -­‐  /ĐĞƌƟĨLJƚŚĂƚƚŚĞŝŶĨŽƌŵĂƟŽŶƉƌŽǀŝĚĞĚŝƐĂĐĐƵƌĂƚĞĂŶĚĐŽŵƉůĞƚĞ͘&ƵƌƚŚĞƌŵŽƌĞ͕ďĞƚǁĞĞŶƚŚĞƟŵĞ/ƐƵďŵŝƚƚŚŝƐĨŽƌŵĂŶĚƚŚĞƟŵĞ/ƉĂƌƟĐŝƉĂƚĞĂƐĂǀŽůƵŶƚĞĞƌ͕ /ǁŝůůŝŶĨŽƌŵKƉĞƌĂƟŽŶZĞĚEŽƐĞŽĨĂŶLJĐŚĂŶŐĞƐƚŚĂƚǁŽƵůĚƌĞƐƵůƚŝŶŵLJŶŽůŽŶŐĞƌŵĞĞƟŶŐƚŚĞƐĞůĞĐƟŽŶĐƌŝƚĞƌŝĂ͘  Ͳ/ĂůƐŽĂŐƌĞĞƚŽĐŽŵƉůLJǁŝƚŚƚŚĞǀŽůƵŶƚĞĞƌĐŽŵŵŝƚŵĞŶƚƐĞƚŽƵƚŽŶƉĂŐĞϮŽĨƚŚŝƐĨŽƌŵ͕ǁŚŝĐŚ/ŚĂǀĞƌĞĂĚĂŶĚƵŶĚĞƌƐƚŽŽĚ͘                                                                    /ĚŽŶŽƚǁŝƐŚƚŽďĞĐŽŶƚĂĐƚĞĚďLJKƉĞƌĂƟŽŶZĞĚEŽƐĞĨŽƌƚŚĞϮϬϭϭĐĂŵƉĂŝŐŶ͘

 LJĐŚĞĐŬŝŶŐƚŚŝƐďŽdž͕/ĐŽŶƐĞŶƚƚŽƚŚĞƵƐĞŽĨŵLJŶĂŵĞ͕ŝŵĂŐĞĂŶĚůŝŬĞŶĞƐƐŝŶƚŚĞĨŽƌŵŽĨƉŚŽƚŽŐƌĂƉŚƐĨŽƌƉƌŽŵŽƟŽŶĂůƉƵƌƉŽƐĞƐďLJKƉĞƌĂƟŽŶZĞĚEŽƐĞ͕ŝƚƐ ƉĂƌƚŶĞƌƐ͕ĂĸůŝĂƚĞƐ͕ĂŐĞŶƚƐ͘ĞŵƉůŽLJĞĞƐ͕ƌĞƉƌĞƐĞŶƚĂƟǀĞƐ͕ůŝĐĞŶƐĞĞƐĂŶĚĂƐƐŝŐŶƐ͕ǁŝƚŚŽƵƚŶŽƟĮĐĂƟŽŶŽƌĐŽŵƉĞŶƐĂƟŽŶ͘

Signature  (mandatory)

Date

E͘͘dŚŝƐǀŽůƵŶƚĞĞƌĂƉƉůŝĐĂƟŽŶĨŽƌŵŝƐǀĂůŝĚĨŽƌƚŚĞϮϬϭϬĐĂŵƉĂŝŐŶŽŶůLJ͘/ƚŝƐƐƵďũĞĐƚƚŽĂƉƉƌŽǀĂůĂŶĚĐĂŶďĞƌĞǀŽŬĞĚĂƚĂŶLJƟŵĞ͘

         KEZKDD/dd

         Z^Zs&KZWK>/,<  Checked  by  ;ŶĂŵĞĂŶĚƌĞŐŝƐƚƌĂƟŽŶŶŽ͘Ϳ

 Comments

 Approved  by  (name)  Meets  the  criteria                    yes                  no  Cannot  be  a  driver  Cannot  be  an  escort  driver  Cannot  be  a  navigator

ZĞĂƐŽŶ

 Date

 Date

The  volunteer  has   provided  a  criminal   record  check  Final  result  Accepted ZĞĨƵƐĞĚ

WůĞĂƐĞƌĞƚƵƌŶƚŚŝƐĨŽƌŵĂƐƐŽŽŶ ĂƐƉŽƐƐŝďůĞƚŽ͗


VOLUNTEER COMMITMENT /ĂŐƌĞĞƚŽ͗  ƚĂŬĞĂůůŶĞĐĞƐƐĂƌLJƉƌĞĐĂƵƟŽŶƐƚŽĞŶƐƵƌĞƚŚĞƐĂĨĞƚLJŽĨŵLJƚĞĂŵĂŶĚŽĨKƉĞƌĂƟŽŶZĞĚEŽƐĞĐůŝĞŶƚƐďLJĐŽŵƉůLJŝŶŐǁŝƚŚ͕ĂŵŽŶŐŽƚŚĞƌƐ͕ƚŚĞ,ŝŐŚǁĂLJ   ^ĂĨĞƚLJŽĚĞ;ƐƉĞĞĚůŝŵŝƚƐ͕ƵƐĞŽĨƐĞĂƚďĞůƚƐ͕ƐŝŐŶĂŐĞ͕ƉĂƌŬŝŶŐ͕ĞƚĐ͘Ϳ͘KƉĞƌĂƟŽŶZĞĚEŽƐĞŝƐŶŽƚƌĞƐƉŽŶƐŝďůĞĨŽƌĂŶLJƟĐŬĞƚƐƌĞĐĞŝǀĞĚĚƵƌŝŶŐƚŚĞĐŽƵƌƐĞŽĨ  ŵLJǀŽůƵŶƚĞĞƌĚƵƟĞƐ͘ 

ĐŽŵƉůLJǁŝƚŚƚŚĞKƉĞƌĂƟŽŶZĞĚEŽƐĞĐŽĚĞŽĨĞƚŚŝĐƐ͘

    ^ŽďƌŝĞƚLJ͗/ŵƵƐƚŶŽƚĐŽŶƐƵŵĞĂŶLJĂůĐŽŚŽůŽŶƚŚĞĚĂLJ/ǁŽƌŬǁŝƚŚKƉĞƌĂƟŽŶZĞĚEŽƐĞ͘     ŽŶĮĚĞŶƟĂůŝƚLJ͗ůůŝŶĨŽƌŵĂƟŽŶĂďŽƵƚKƉĞƌĂƟŽŶZĞĚEŽƐĞĐůŝĞŶƚƐĂŶĚǀŽůƵŶƚĞĞƌƐƚŚĂƚŝƐĚŝƐĐůŽƐĞĚƚŽŵĞǁŝůůƌĞŵĂŝŶĐŽŶĮĚĞŶƟĂůĂŶĚǁŝůů    ŶŽƚďĞƵƐĞĚĨŽƌĂŶLJƉƵƌƉŽƐĞŽƚŚĞƌƚŚĂŶĨƵůĮůůƚŚĞŵĂŶĚĂƚĞĐŽŶĨĞƌƌĞĚƵƉŽŶŵĞ͘/ǁŝůůĂůƐŽŶŽƚĚŝƐĐƵƐƐĂŶLJĚĞƚĂŝůƐǁŝƚŚŽƚŚĞƌǀŽůƵŶƚĞĞƌƐƚŚĂƚ   ĐŽƵůĚďĞƵƐĞĚƚŽŝĚĞŶƟĨLJĂĐůŝĞŶƚŽƌǀŽůƵŶƚĞĞƌ͘     ŽƵƌƚĞƐLJ͗/ǁŝůůƐŚŽǁƉĂƟĞŶĐĞĂŶĚĐŽƵƌƚĞƐLJƚŽǁĂƌĚĐůŝĞŶƚƐĂƚĂůůƟŵĞƐ͘     &ƌĞĞƐĞƌǀŝĐĞ͗KƉĞƌĂƟŽŶZĞĚEŽƐĞŝƐĂĨƌĞĞƐĞƌǀŝĐĞ͘/ǁŝůůŶĞǀĞƌƐŽůŝĐŝƚĚŽŶĂƟŽŶƐ͕ďƵƚŝĨĐůŝĞŶƚƐǁŝƐŚƚŽŵĂŬĞĂĚŽŶĂƟŽŶ͕/ǁŝůůƚŚĂŶŬƚŚĞŵ͘     &ĂƟŐƵĞ͗KƉĞƌĂƟŽŶZĞĚEŽƐĞǀŽůƵŶƚĞĞƌƐŵƵƐƚŽŌĞŶĚĞĂůǁŝƚŚĨĂƟŐƵĞ͕ĂŶĚŝƚƐĞīĞƚƐĂƚŶŝŐŚƚŵƵƐƚŶŽƚďĞƵŶĚĞƌĞƐƟŵĂƚĞĚ͘dŚĞƌĞĨŽƌĞ͕/ǁŝůů ŶŽƚŽǀĞƌĞƐƟŵĂƚĞŵLJĐĂƉĂďŝůŝƟĞƐĂŶĚ͕ŝĨŶĞĐĞƐƐĂƌLJ͕/ǁŝůůƚĂŬĞĂŶĂƉďĞĨŽƌĞƌĞƉŽƌƟŶŐĨŽƌĚƵƚLJĂƐĂŶKƉĞƌĂƟŽŶZĞĚEŽƐĞǀŽůƵŶƚĞĞƌ͘     DƵƚƵĂůƌĞƐƉĞĐƚ͗ůůKƉĞƌĂƟŽŶZĞĚEŽƐĞǀŽůƵŶƚĞĞƌƐ͕ǁŚĞƚŚĞƌƚŚĞLJǁŽƌŬŝŶƚŚĞŽĸĐĞŽƌŽŶƚŚĞƌŽĂĚ͕ĚĞƐĞƌǀĞŵLJĨƵůůƌĞƐƉĞĐƚĂŶĚĐŽŶƐŝĚĞƌĂͲ   ƟŽŶ͘ 

ƌĞƚƵƌŶƚŽKƉĞƌĂƟŽŶZĞĚEŽƐĞĂůůĂŵŽƵŶƚƐŐŝǀĞŶƚŽŵĞ;ĚŽŶĂƟŽŶƐ͕ƟƉƐ͕ŐŝŌƐ͕ĞƚĐ͘Ϳ͘

/Ĩ/ĚŽŶŽƚŚŽŶŽƵƌŵLJĐŽŵŵŝƚŵĞŶƚ͕KƉĞƌĂƟŽŶZĞĚEŽƐĞƌĞƐĞƌǀĞƐƚŚĞƌŝŐŚƚƚŽƚĞƌŵŝŶĂƚĞŵLJƉĂƌƟĐŝƉĂƟŽŶĂƐĂǀŽůƵŶƚĞĞƌĨŽƌƚŚĞĐƵƌƌĞŶƚĂŶĚĨƵƚƵƌĞ ĐĂŵƉĂŝŐŶƐ͘dŚĞĚĞĐŝƐŝŽŶŽĨKƉĞƌĂƟŽŶZĞĚEŽƐĞŝƐĮŶĂů͘

VOLUNTEER DUTIES YOU ARE INTERESTED IN WůĞĂƐĞĐŚĞĐŬƚŚĞďŽdžŽĨƚŚĞĚƵƟĞƐƚŚĂƚŝŶƚĞƌĞƐƚLJŽƵ͘&ŽƌŽĸĐĞĚƵƟĞƐ͕ƉůĞĂƐĞĐŽŶƚĂĐƚLJŽƵƌůŽĐĂůKƉĞƌĂƟŽŶZĞĚEŽƐĞŽƌŐĂŶŝnjĂƟŽŶ͘ Person  who  escorts  the  driver  and   the  navigator  in  his  or  her  own   vehicle.

Escort   driver

DƵƐƚďĞϭϵLJĞĂƌƐŽĨĂŐĞŽƌŽůĚĞƌ Must  have  a  valid  driver’s  licence  and  a  vehicule

Person  who  drives  the  client’s   vehicle.

Driver

DƵƐƚďĞϮϭLJĞĂƌƐŽĨĂŐĞŽƌŽůĚĞƌ Must  have  a  valid  driver’s  licence

ͲWůĞĂƐĞŝŶĚŝĐĂƚĞLJŽƵƌĚƌŝǀĞƌ͛ƐůŝĐĞŶĐĞĮůĞŶƵŵďĞƌŽŶƚŚĞ -­‐  Please  carefully  complete  the  Driver’s  Licence  and   reverse.   Insurance  CompanyƐĞĐƟŽŶƐŽŶƚŚĞƌĞǀĞƌƐĞ͘ -­‐  You  must  carry  your  driver’s  licence  with  you  on  the   ͲKƉĞƌĂƟŽŶZĞĚEŽƐĞŽŶůLJŝŶƐƵƌĞƐĞƐĐŽƌƚĚƌŝǀĞƌƐǁŚŽƐĞ ŶŝŐŚƚŽĨLJŽƵƌƐŚŝŌǁŝƚŚKƉĞƌĂƟŽŶZĞĚEŽƐĞ͘ vehicles  are  insured  against  damage. -­‐  You  must  carry  your  proof  of  insurance  and  your  driver’s   ůŝĐĞŶĐĞǁŝƚŚLJŽƵŽŶƚŚĞŶŝŐŚƚŽĨLJŽƵƌƐŚŝŌǁŝƚŚKƉĞƌĂƟŽŶ ZĞĚEŽƐĞ͘

INFORMATION Please circle the date you are available. A minimum of 48 hours is needed to process your application after it is received.

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Navigator

Person  who  rides  with  the  driver  in   the  client’s  vehicle.

DƵƐƚďĞϭϵLJĞĂƌƐŽĨĂŐĞŽƌŽůĚĞƌ ƌŝǀĞƌ͛ƐůŝĐĞŶĐĞŶŽƚŵĂŶĚĂƚŽƌLJ͕ ďƵƚŝŶĚŝĐĂƟŶŐƚŚĞŶƵŵďĞƌŽŶƚŚĞƌĞǀĞƌƐĞǁŝůů ƐƉĞĞĚƵƉƚŚĞƉƌŽĐĞƐƐŝŶŐŽĨLJŽƵƌĂƉƉůŝĐĂƟŽŶ͘


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