Revised 6.30.2021
New Updated
As a volunteer driver at Scottsdale Christian Academy (SCA), and using my own personal vehicle to transport SCA students, I attest that
I have a good driving record, that my vehicle is in good repair and that I carry and maintain adequate insurance coverage as required by
the State of Arizona of every driver owning and operating a motor vehicle.
Further, as a volunteer driver for the above-mentioned SCA event/function, I hereby recognize and acknowledge that I am fully and
solely responsible for the safety, care and well-being of any and all SCA students riding in my vehicle; and that in the event of an
accident or mishap of any type whatsoever involving my vehicle and SCA students, I assume the primary position for any and all liability,
medical and/or other damage claim(s) that might arise.
By signing below, I understand that as a volunteer when I drive my personal vehicle on school business or for a school activity, my
personal auto insurance will be primary to the insurance carried by the school. I acknowledge having read the above statement and my
intent to comply with all terms and conditions thereof.
SECTION 1: Please complete all driver information fields.
SECTION 2: Please complete all driver history questions for the past 3 years. Signature is required.
SECTION 3: Complete the following Volunteer Driver Release. Signature is required.
ALL VOLUNTEER FORMS MUST BE SIGNED BEFORE SUBMITTING. ALL VOLUNTEER FORMS MUST BE SIGNED BEFORE SUBMITTING.
If you answered YES to any of the above questions, please provide full details below: Include complete
explanation of the dates, amounts, posted and clocked speed, full disclosure.
NOTE: Coverage is not bound if any questions 1-6 is answered YES.
*** If the above information changes during the year and you continue to drive your personal vehicle, please update this form. ***
Use black ink and print clearly. Form must be legible.
Driver: Today’s Date:
Purpose driving:
Driver Name:
Birth Date:
State:
State: Zip: Telephone:
Address: City:
Out of State D/L? Why?
Driver’s License No.: Exp. Date:
M F
Sex:
Teacher/Class:
Date of Event:
Scottsdale Christian Academy Vehicle Insurance
Policy Number 02APA247330
OFFICE USE:
Submitted to Insurance:
Make
Insurance Carrier
Agent Name Telephone
Policy Number Expiration Date
Model Year
Signature Required
Driver Signature Date
Must be exactly as on driver’s license. Please print clearly. Must be legitable.
DRIVER INFORMATION
/ /
Yes No
1. Have you been involved in any accidents?
2. Were you at fault?
3. Have you had any moving traffic violations?
4. Have you had any company cancel or refuse to provide your auto insurance?
5. Have you had your driver’s license revoked, suspended or restricted?
6. Do you have any physical impairment other than corrective glasses?
Yes
Yes
Yes
Yes
Yes
Yes
No
No
No
No
No
No
NO TEXTING ALLOWED WHILE DRIVING
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