Volunteer Application Form Volunteer Application Form All participates in CARS must complete a Volunteer Application form including all the requested information prior to being eligible for service. The confidentiality of provided information will be respected. All Volunteer Application forms must be signed by the participant. Name First Last Address Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAntigua and BarbudaArgentinaArmeniaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBosnia and HerzegovinaBotswanaBrazilBruneiBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCosta RicaCôte d'IvoireCroatiaCubaCuraçaoCyprusCzech RepublicDenmarkDjiboutiDominicaDominican RepublicEast TimorEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEthiopiaFaroe IslandsFijiFinlandFranceFrench PolynesiaGabonGambiaGeorgiaGermanyGhanaGreeceGreenlandGrenadaGuamGuatemalaGuineaGuinea-BissauGuyanaHaitiHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsraelItalyJamaicaJapanJordanKazakhstanKenyaKiribatiNorth KoreaSouth KoreaKosovoKuwaitKyrgyzstanLaosLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMauritaniaMauritiusMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew ZealandNicaraguaNigerNigeriaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPolandPortugalPuerto RicoQatarRomaniaRussiaRwandaSaint Kitts and NevisSaint LuciaSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSpainSri LankaSudanSudan, SouthSurinameSwazilandSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTogoTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTuvaluUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVatican CityVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.YemenZambiaZimbabwe Country Home PhoneCell PhoneWork PhoneEmail VOLUNTEER DRIVERS MUST COMPLETE THE REST OF THIS FORM, OTHERS MAY SKIP TO SIGNATURE BLOCK.Vehicle 1Type/YearLicense #CapacityWheel Chair Equipped:YesNoVehicle 2Type/YearLicense #CapacityWheel Chair Equipped:YesNoVehicle 3Type/YearLicense #CapacityWheel Chair Equipped:YesNoInsurance Co.Policy #Please upload a copy of Proof of InsuranceAccepted file types: jpg, gif, png, pdf, doc, docx.File extensions allowed: jpg, gif, png, pdf, doc, docxTexas Driver's License #Please upload a copy of your Driver's LicenseAccepted file types: jpg, gif, png, pdf, doc, docx.File extensions allowed: jpg, gif, png, pdf, doc, docxPersonal InformationWould you have any difficulty dealing with a rider who required the use of the any of the following?WHEELCHAIRYesNoCANEYesNoWALKERYesNoCRUTCHESYesNoSCOOTERYesNoDOGYesNoOXYGEN EQUIPMENTYesNoEmergency ContactPhone NumberPrimary Care PhysicianPhone NumberDo you have any physical or emotional conditions that may limit or impair your driving and/or are you currently taking and drugs that may impair your driving?YesNoDRIVING RECORD (LAST 5 YEARS)Please list below the date and a description of any major accident in which you were deemed to be at-fault, or any convictions that you may have had for a moving violation.1.)2.)3.)4.)5.)Have you ever been denied a license, permit or privilege to operate a motor vehicle?YesNoHas any license, permit or privilege ever been suspended or revoked?YesNoSpecial CertificatesCPRDescription and ExpirationMedicalDescription and ExpirationDefensive DrivingDescription and ExpirationFirst AidDescription and ExpirationOtherDescription and ExpirationPolicies and Procedures: I agree to read, respect, follow and abide by the policies and procedures of CARS as my be set forth in writing from time to time. I also understand that it is the law for all occupants of a motor vehicle be seat-belted while the vehicle is in operation. I will promptly report any moving violations or at-fault accidents that occur during my tenure as a volunteer driver whether or not they occur while driving for CARS. I also agree to maintain, at all times, at least the state mandated minimum vehicle insurance on my personal vehicles. Provision of Personal Vehicle: If I use my personal vehicle in the service of CARS, I understand that I am to bear the full cost of fuel, oil, repairs, maintenance and insurance for my personal vehicle and that CARS will not reimburse me for any of these expenses.Emergency Treatment Release and Liability Waiver: Emergency Treatment Release and Liability Waiver: I certify that I have truthfully provided all requested information and that I understand the dangers inherent in my participation in the services provided by Call A Ride of Southlake, Inc., "CARS". I hereby authorize CARS to validate any information that I have provided and to seek and obtain emergency medical treatment on my behalf, including transportation to the nearest medical facility in the event that CARS deems it necessary. I hereby relieve CARS, its employees, volunteers, agents, instructors and sponsors of all liability that may occur due to my participation in any CARS activity. I further certify that I am medically sound enough to participate in the CARS program, that I have read and understood this form and that all entries and information herein are true and complete.Print Applicant's NameDate SignatureDate This iframe contains the logic required to handle AJAX powered Gravity Forms.