Volunteer Registration Form

Name*

First Last

Date of Birth*

Address*

Street Address City Province Postal Code

Phone number*

Email Address

Occupation

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

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?

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