Volunteer to Transport Students

Name *

First Name

Last Name

Date of Birth *

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Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Cell Phone *

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Home Phone

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Work Phone

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Name *

First Name

Last Name

Cell Phone *

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Home Phone

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Work Phone

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Expiration Date *

MM

DD

YYYY

Expiration Date

MM

DD

YYYY

I am at least 21 years of age. *

Yes

No

I have a valid Ontario Driver’s License. *

Yes

No

I have an active auto liability insurance policy that carries a minimum of one million dollar coverage. The policy includes coverage for general liability, bodily injury, property damage, and uninsured motorist. *

Yes

No

I understand that if I am involved in a motor vehicle accident while driving my personal vehicle on school related business, that my personal auto insurance policy will be considered the primary insurance coverage, and that any and all claims will be submitted to my personal insurance carrier for payment. *

Yes

No

I certify that my vehicle has no known mechanical defects, and no known safety deficiencies. *

Yes

No

I certify that all occupants of any vehicle I use to transport students will be required to individually wear a seat belt, including both driver and passengers. I will not allow any student to ride in the front passenger seat if they are less than 12 years old, or weigh less than 100 pounds. *

Yes

No

I understand that I may only transport students in vehicles with a rated capacity of 8 passengers, including the driver or less. Any vehicles with a greater than 8 passenger rated capacity are prohibited. *

Yes

No

I agree to report to the head of school regarding any and all accidents, regardless of how minor, that I am involved in while transporting staff, volunteers or students. *

Yes

No

I certify that I have no known medical condition that would adversely affect my ability to safely transport students in a motorized vehicle. *

Yes

No

I have had a vehicle violation(s) within the last three years. If yes, please list details below. *

Yes

No

Applicant Signature *

By checking this box, I certify all information is true and correct to the best of my knowledge.