DRIVER APPLICATION DRIVER REGISTRATION FORM Please enable JavaScript in your browser to complete this form.Please enable JavaScript in your browser to complete this form.Name: *FirstMiddleLastDate of Birth: *Phone Number: *Email: *Emergency Contact Name: *FirstLastRelationship with Emergency Contact: *Emergency Contact Primary Phone: *Emergency Contact Alternate Phone: *Emergency Contact Email: *Driver's License #: *License State: *SelectAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingExpiration Date: *I am generally available to drive: *WeekdayWeekendMorningAfternoonEveningVariesI am willing to drive in inclement weather: *YesNoPlease explain why you chose yes or no for the question above: *I am willing to drive in Ridgefield: *YesNoI am willing to drive in Greater Danbury area: *YesNoI am willing to drive in Greater Norwalk area: *YesNoI am willing to drive in Westchester County NY: *YesNoI am willing to drive in Other areas: *YesNoIf you said you are willing to drive in Other areas, what would those other areas be?Rider Accommodations - There may be certain rider accommodations that you are not comfortable in managing. Please indicate any accommodation restrictions you might have in driving Ridgefield seniors and residents who have mobility disabilities.I am willing to escort riders curb-to-curb: *YesNoI am willing to escort riders to-the-door: *YesNoI am willing to escort riders thru-the-door: *YesNoI am willing to drive riders using walkers: *YesNoI am willing to drive riders using wheelchairs: *YesNoI am willing to drive riders using medical equipment (e.g., oxygen): *YesNoI am willing to drive riders with animals: *YesNoI am willing to drive a child using a car seat (all minors must be accompanied by an adult): *YesNoI am willing to OTHER (please describe):YesNoIf you chose OTHER, please describe what else you are willing to do that has not been previously stated:Please check the following to continue: *I certify that I am currently licensed to drive a passenger vehicle in the State of Connecticut.Further, I agree to immediately notify Rides For Ridgefield in the event that my driver’s license is suspended or revoked or if I have been involved in any accident or moving violation.Further, I certify that I am not taking any medications or substances nor have any medical conditions which would impair my ability to drive safely.Further, I certify that I am physically able to carry out essential volunteer driver functions. These functions include safely transporting Ridgefield seniors and residents who have mobility disabilities to and from their ride destinations and reasonably assisting riders as needed during pick-up and drop off.Further, I certify that I will follow Rides For Ridgefield’s Volunteer Driver Program Procedures and Guidelines.Further, I authorize Rides For Ridgefield to make periodic checks of my driving and criminal record.Signature * Clear Signature Date Signed *Submit