St. Mary Volunteer Driver Form

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St. Mary Catholic Schools - Dell Rapids
Form intended for volunteer parent drivers

Email *

NAME *

DATE OF BIRTH *

YYYY

ADDRESS *

CITY / STATE / ZIP *

PHONE *

CELL PHONE *

DRIVER'S LICENSE # *

DRIVER'S LICENSE STATE ISSUED AND EXPIRATION DATE *

INSURANCE COMPANY *

POLICY # AND EXPIRATION DATE *

(Please note: As a volunteer driver, in the event of an accident, your insurance will serve as primary insurer. Liability coverage provided by the parish/school is secondary.)

Have you had any of the following citations or convictions in the past THREE years?:

Driving under the influence of alcohol or drugs? *

Yes

Hit and Run? *

Yes

Failure to report an accident? *

Yes

Negligent homicide arising out of the use of a motor vehicle? *

Yes

Using a motor vehicle for the commission of a felony? *

Yes

Permitting an unlicensed person to drive? *

Yes

Reckless Driving? *

Yes

Three or more moving violations or accidents? *

Yes

CERTIFICATION

My signature below certifies that the information given on this form is true and correct to the best of my knowledge and that I agree to the following:
* I understand that driving for Church ministry is an important responsibility and I will exercise care and due diligence while driving.
* I understand that as a volunteer driver, I must be 21 years of age.
* I certify that I possess a valid driver's license and have the proper and current vehicle license and registration.
* I certify that I have the required insurance coverage in effect on the vehicle I will be driving for the event.
* I understand that I cannot use a passenger van designed to seat 11-15 persons when transporting students.
* I agree that I will refrain from using a cell phone or any other electronic device while operating my vehicle.
* I agree to adhere to the State of South Dakota safety belt laws and regulations.
* I certify that the level of insurance on my vehicle is consistent with the liability limit requirements of the State of South Dakota
($100,000/$300,000)

By completing this form, entering your name below and the date, you agree you have answered the questions above truthfully and to the best of your knowledge . *

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