Volunteer Registration Form

If you have any questions about this form please contact us at (506) 466-4444.

First Name (required):

Last Name (required):

Street Address (required):

Town/Village (required):

Province (required):

Postal Code (required):

Phone Number (required):

Email Address:

Occupation:

Please indicate the time slots you would be available for on a weekly basis:

 Monday 9:00am - 1:00pm Monday 1:00pm - 5:00pm Tuesday 9:00am - 1:00pm Tuesday 1:00pm - 5:00pm Wednesay 9:00am - 1:00pm Wednesday 1:00pm - 5:00pm Thursday 9:00am - 1:00pm Thursday 1:00pm - 5:00pm Friday 9:00am - 1:00pm Friday 1:00pm - 5:00pm

Drivers license number:

What is the make, model and year of your vehicle(s)?

Are you comfortable providing assistance to people with physical disabilities if necessary?

 Yes No

Do you have any experience assisting people with disabilities? Please describe:

Some clients may require extra help or need you to stay with them during their outing. Are you willing/able to assist in this regard when necessary?

 Yes No

For security reasons, would you agree to a criminal record background check by the RCMP and a background check with the records held with the New Brunswick Family and Community Services?

 Yes No

Would you be willing to sign an oath of confidentiality stating your intent to keep confidential any information you are made privy to regarding our clients?

 Yes No

Would you be willing to provide a copy of your driving record?

 Yes No

Are you willing to incur the cost of upgrading your personal vehicle insurance to a $2M minimum coverage (estimated cost $40-$60 per year)? (We can reimburse for the increased portion up to $100 if requested).

 Yes No

Are you willing to donate some or all of your services without compensation for fuel costs on a kilometer basis? (If you choose to accept the mileage reimbursement, you could choose to donate it back occasionally in exchange for a charitable receipt.)

 Yes No

Is there any other information that might affect your ability to provide volunteer driver service that we should be aware of?