Fillable Out %26 About Volunteer Driver Application With DMV Authorization Form

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Out %26 About Volunteer Driver Application With DMV Authorization Form

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Out & About Transportation Volunteer Driver Application Packet
Thank you for considering Encinitas Out and About Senior Transportation for your
volunteer services. Our volunteers offer their time by driving eligible seniors over the
age of 50 to various appointments and errands, helping to keep them independent and
in their homes longer. The program is a great way to give back to your community.
Volunteers can donate as little as two hours per week or as many as forty.
The Program offers flexibility to accommodate your schedule
As a small token of appreciation and to help offset the cost of gas, the City of Encinitas
offers mileage reimbursement to our volunteers. For every mile you drive a registered
Out & About passenger, you will be reimbursed at the annual IRS rate.
If this volunteer opportunity seems like a good fit for you, call today at (760) 943-2256.
We will be glad to answer any questions you may have. Please fill out the attached
application and include copies of the following documents:
Automobile insurance Automobile registration
DMV Pull Program Driver’s License
Once the application is completed and returned to the Encinitas Senior Center, contact
Human Resources, Cathy Godfrey at (760) 633-2644 or email her at
cgodfrey@encinitasca.gov for Background Screening which will include:
Live Scan request
Thank you for your interest in our program and sharing your time and skills. Every ride
that you provide makes a difference for a senior in our community.
Regards,
Out & About Coordinator
City of Encinitas/Senior Center
(760) 943-2256
Volunteer Driver Application
Driver’s First & Last Name Date of Birth (Month-Day-Year)
Address City State Zip Code
Home Phone Cell Phone
Email Address
Driver’s License Number
Name of Auto Insurance Company Policy Number
1. Do you have previous volunteer experience? Yes No If yes, please list
where.
________________________________________________________________
2. Briefly explain why you are interested in volunteering as a driver for the Out and
About Program?
________________________________________________________________
3. How did you hear about our volunteer program?
________________________________________________________________
4. To qualify as a volunteer driver, you must be at least 21 years of age. Please
verify your age.
5. Have you had any traffic violations within the last 3 years? Yes No If yes,
please give a brief description of the violation.
________________________________________________________________
6. Have you had a traffic accident within the last 5 years? Yes No If yes,
please give a brief description of the violation.
________________________________________________________________
7. Do you have any physical limitations or take any medications that may have an
effect on your driving ability? Yes No
8. What days are you available to volunteer?
Sunday
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
9. How many passengers are you willing to transport? _______________________
10. Provide any additional information on availability:
________________________________________________________________
Personal References
Please list 2 references that do not include family members.
Name
Phone
Relationship
Name
Phone
Relationship
If you answered YES to question #7, please have your physician complete the
following:
I hereby state that _______________________________________is mentally,
physically, and otherwise capable of safely operating a private automobile.
_______________________________________________________________
Physician’s Signature Date
Statement of Understanding
1. My purpose as a volunteer driver is to provide safe, reliable and friendly
transportation to and from essential services (e.g. medical facilities, social
services, nutrition sites, etc.) for older adults living within the City of Encinitas,
California.
2. I understand that I am required to meet the following minimum standards for
motor vehicle insurance. My personal insurance is the primary liability protection
and must be issued by a company authorized to do business in the state of CA. I
understand that there will be a gap of coverage if my insurance does not reach
the City’s excess policy level.
The following minimum insurance coverage is required by the State of California:
$ 15,000 bodily injury, each person
$ 30,000 bodily injury, each accident
$ 5,000 property damage
3. I will provide proof of coverage of my vehicle insurance and in the event that my
coverage changes or is canceled, I will immediately notify the Senior Center Out
& About Coordinator of such changes or cancellations.
4. I will notify immediately and provide the Senior Center Out & About Coordinator
with a copy of any accident reports, in the event that I am involved in a vehicle
accident or any traffic citation that I may receive while this agreement is valid.
5. I am physically capable of driving my private vehicle for the Out & About
Encinitas Program and will not drive while using any drug that may affect my
driving ability, either prescription or “over the counter.”
6. I agree to keep my vehicle mechanically sound and equipped with seat belts
which I will use and enforce my passengers to use.
7. Any traffic violations and citations will be my responsibility.
8. I understand by participating in the Out & About Program that I do so at my own
free will and assume all risks associated with participation. I myself, and anyone
entitled to act on my behalf, agree to waive and release the City of Encinitas, its
elected officials, officers, agents, employees, and volunteers from any all claims
of liabilities of any kind arising from my participation in the program.
9. I will maintain true and accurate records required by Out & About Encinitas.
10. I will notify the Out & About Encinitas Coordinator at the time I no longer wish to
be involved in this program. Either the Out & About Encinitas Senior Staff, or I,
may terminate this agreement at any time.
Things to Know as a Volunteer Driver
• You will transport eligible senior citizens in your private vehicle.
• I agree to transport seniors in a safe, efficient manner in my private vehicle.
• All passengers must be registered and approved through the Out & About
Transportation Program. To be eligible, passengers must be at least 50 years of
age and live in the City of Encinitas with a zip code of 92024 or 92007.
• Transportation boundaries include all of Encinitas/Cardiff. You may also travel
between Oceanside and San Diego to medical facilities and government agencies.
• Travel arrangements are made between passenger and driver and all information
about your passenger(s) is to be kept confidential.
• If you reside outside of Encinitas, the mileage reimbursement will begin when you
reach the city limits of Encinitas. For residents, your mileage begins when you
leave your home. Once your passenger(s) is in your vehicle, you will be permitted
to travel and receive reimbursement for the approved destinations.
• Volunteers may not accept monetary tips from passengers. Donations should be
encouraged to go directly to the Out & About Program where the funds will be used
for continuation of the program.
• You will receive the current annual IRS rate up to 100 miles per passenger, per
month.
• Responsible for logging your monthly mileage on the provided form.
• Mail or drop off your mileage form by the 5
th
of the following month.
• Checks are issued to you monthly within 3 weeks of receiving your form.
I have read, understand, and agree to all statements in the volunteer application packet.
Print Name
Signature
Date
For City Use Only
Approved
Denied
Reason Denied:
Approved by City Staff:
Date:
A Public Service Agency
EMPLOYER PULL NOTICE PROGRAM
AUTHORIZATION FOR
RELEASE OF DRIVER RECORD INFORMATION
I, _________________________________________, California Driver License Number, _____________________________,
hereby authorize the California Department of Motor Vehicles (DMV) to disclose or otherwise make available, my driving
record, to my employer, ________________________________________________________________________________
COMPANY NAME
I understand that my employer may enroll me in the Employer Pull Notice (EPN) program to receive a driver record report
at least once every twelve (12) months or when any subsequent conviction, failure to appear, accident, driver’s license
suspension, revocation, or any other action is taken against my driving privilege during my employment.
I am not driving in a capacity that requires mandatory enrollment in the EPN program pursuant to California Vehicle Code
(CVC) Section 1808.1(k). I understand that enrollment in the EPN program is in an effort to promote driver safety, and that
my driver license report will be released to my employer to determine my eligibility as a licensed driver for my employment.
EXECUTED AT: CITY
COUNTY
STATE
DATE
SIGNATURE OF EMPLOYEE
X
I, _____________________________________________, of ___________________________________________________
AUTHORIZED REPRESENTATIVE COMPANY NAME
do hereby certify under penalty of perjury under the laws in the state of California, that I am an authorized representative
of this company, that the information entered on this document is true and correct, to the best of my knowledge and that I
am requesting driver record information on the above individual to verify the information as provided by said individual. This
record is to be used by this employer in the normal course of business and as a legitimate business need to verify information
relating to a driving position not mandated pursuant to CVC Section 1808.1. The information received will not be used for
any unlawful purpose. I understand that if I have provided false information, I may be subject to prosecution for perjury
( Penal Code Section 118 ) and false representation ( CVC Section 1808.45 ). These are punishable by a fine not exceeding
five thousand dollars ( $5,000 ) or by imprisonment in the county jail not exceeding one year, or both fine and imprisonment.
I understand and acknowledge that any failure to maintain confidentiality is both civilly and criminally punishable pursuant
to CVC Sections 1808.45 and 1808.46.
EXECUTED AT: CITY
COUNTY
STATE
DATE
SIGNATURE AND TITLE OF AUTHORIZED REPRESENTATIVE
X
To obtain a driver record on a prospective employee you may submit an INF 1119 form. To add this driver to the EPN Program
you must submit the applicable form: INF 1100, INF 1102, INF 1103, INF 1103A form. You may obtain forms at our website
at www.dmv.ca.gov/otherservices, or by calling 916-657-6346.
THIS FORM MUST BE COMPLETED AND RETAINED AT THE EMPLOYER’S PRINCIPAL PLACE OF BUSINESS AND
MADE AVAILABLE UPON REQUEST TO DMV STAFF.
DO NOT RETURN THIS FORM TO DMV.
City of Encinitas
Encinitas
San Diego
California
Cathy Godfrey
City of Encinitas
Encinitas
San Diego
California
Cathy Godfrey / Program Assistant / Human Resources
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Out %26 About Volunteer Driver Application With DMV Authorization Form

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Completed 12 July 2020

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