VOLUNTEER APPLICATION VOLUNTEER REGISTRATION FORM Please enable JavaScript in your browser to complete this form.Please enable JavaScript in your browser to complete this form.Name: *FirstLastAddress: *Address Line 1Address Line 2City--- Select state ---AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingStateZip CodePhone (Primary): *Phone (Alternate):Email: *Why are you interested in becoming a Rides For Ridgefield volunteer? Please include skills, interests & experience. *Please indicate any additional language skills. *Reference Name: *FirstLast(preferably current Ridgefield resident)Reference Phone: *Reference Email: *What volunteer opportunities interest you?DrivingCall CenterFundraisingMarketingInformation Tech (website, etc.)Community RelationsBoard of DirectorsOther (please specify)If you chose Other, please specify here:Please list each vehicle you may use to drive a client/rider: Vehicle #1 Make/Model/Year: *Please list the insurance company (s) covering your car(s): *Please list each vehicle you may use to drive a client/rider: Vehicle #2 Make/Model/Year: Please list the insurance company (s) covering your car(s):Please check the following to continue: *I hereby declare the information provided by me in this application is true and complete, and I understand that falsification of this information is ground for refusal to accept me as a volunteer, or if accepted, termination.I authorize the persons or organizations referenced in this application to give you any and all information concerning my previous experience, education, or any other information that they might have personal or otherwise, with regard to any of the subjects covered by this application; and I release all such parties from all liability for any damage which may result from furnishing such information to you.I authorize you to request, receive and verify all information given in this application.Please check the following to continue (Volunteer Drivers Only): *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.Please check the following to continue (Volunteer Drivers Only): *I certify that I am currently insured through the above insurance company (attached copy of my insurance identification card) for automobile liability insurance in an amount in excess of or equal to the minimum required under Connecticut State law (minimum of $20,000 per person and $40,000 per accident for bodily injury liability and $10,000 per accident for property damage liability).I agree to forward a photocopy of my Proof of Insurance Card at each renewal periodI agree to immediately notify Rides For Ridgefield in the event that the above liability insurance is revoked, cancelled or altered in such a manner as to no longer meet the minimum vehicle insurance requirements for the State of Connecticut.I agree not to transport any passengers as part of the volunteer driver program if these minimums liability requirements are not met, or if my Connecticut vehicle operator’s license is not current and/or valid, or if the registration and license of the vehicle (s) I use to transport riders is not current and/or valid.I certify that my vehicle(s) is in safe operating condition and will be maintained in safe operating condition while I continue as a volunteer driver.Signature * Clear Signature Date Signed *Submit
