Transportation Volunteer Form

The information that you have been asked to provide is for the purpose of arranging a suitable volunteer driver with a qualified senior. Acceptance of this application is not a guarantee of participation. A Senior Services staff member will contact you regarding the status of your application. We make every effort to maintain confidentiality regarding personal information given

Full Name(Required)

Preferred Name

Preferred Nickname

Phone(Required)

Email(Required)

Date of Birth(Required)

Address(Required)

Street Address Address Line 2 City State ZIP Code

County(Required)

How did you hear about us?(Required)

Emergency contact phone:(Required)

Emergency contact:(Required)

Marital Status(Required)

Single

Married

Divorced

Widowed

Other

Spouses Name

Primary language:

Other languages spoken:

Are you a Veteran (if yes, Branch of Service):

Employment(Required)

Full time

Part time

At home

Retired

Do you carry liability insurance?(Required)

Yes

No

Car Insurance Company:(Required)

Vehicle Make(Required)

Vehicle Model(Required)

Vehicle Year(Required)

Vehicle Color(Required)

Driver's license #/ State ID #:(Required)

Expires:(Required)

Please indicate the days that you are available(Required)

Please hold the Ctrl button down to select more than one selection

# of Rides Available to Provide a Week(Required)

Please select only one choice

Please indicate the areas that you are willing to drive to /driving radius?(Required)

How did you hear about the transportation program?

CONSENT FOR CRIMINAL BACKGROUND CHECK

I hereby give my permission for the Illinois State Police to obtain information relating to my criminal history record through Senior Services Associates. The criminal history record, as received from the reporting agencies, may include arrest and conviction data. I understand that this information will be used in part, to determine my eligibility for a volunteer position with this organization. I also understand that as long as I remain a volunteer here, the criminal history records check may be repeated at any time.

I understand that I will have an opportunity to review the criminal history and a procedure is available for clarification, if I dispute the record as received. I, the undersigned, do, for myself, my heirs, executors and administrators, hereby remise, release and forever discharge and agree to indemnify and hold the Senior Services Associates and officers, directors, employees, and agents harmless from and against any and all causes of actions, suits, liabilities, costs, debits and sums of money, claims and demands whatsoever, and any and all related attorneys’ fees, court costs, and other expenses resulting from the investigation of my background in connection with my application to become a volunteer.

Name(Required)

Maiden Name

DOB(Required)

Gender

Race

Signature(Required)

Date(Required)

GRATUITY POLICY

By submitting this form, you understand and agree to the following:

No one should accept money or gifts from any client of Senior Services Associates. The acceptance of money or gifts leaves recipients open to the suggestion that they have been placed under a sense of obligation. However, receiving modest token gifts such as baked goods, executed with good judgment, and in moderation, such an occasional exchange is acceptable. It is expected that such gifts are received only during birthday/ the Christmas holiday season.

Volunteers may not accept money from Senior Services Associates clients or their families. Please direct the client or their family member to mail their donation directly to Senior Services’ office. If the volunteer would like to keep donation envelopes in his or her vehicle, they may do so. Donation envelopes may be obtained from the Senior Services Associates office. It will be the responsibility of the client or client’s family member to return the envelope to Senior Services.

Signature

AUTHORIZATION TO PHOTOGRAPH/VIDEO/FILM/SOCIAL MEDIA

I give permission to the staff and/or agents of Senior Services Associates to photograph/videotape/film/social media and to use my name for release for the following purpose(s):

Signature

This consent for disclosure is valid for the life of the photograph, its negative, videotape, brochure, newsletter, annual report, and/or posting on website or social media. Photographs including negative/videotape/films/social media posts may be archived for future use as noted above. The undersigned does hereby release Senior Services Associates and its successors and assigns from any and all claims for damages for libel, slander and invasion of privacy, or any other claims based on the use of said materials.

I understand that I have the right to inspect and copy the information to be disclosed. I understand that I may revoke this consent by written request at any time. I understand that my refusal to consent to disclosure will result in the photograph/videotape/film/social media post not being disclosed. When photographs/videotapes/films/social media posts are used following this authorization, they may be subject to redisclosure by the recipient and may not be protected by this rule.

I understand that my name will not be released with the aforementioned materials without the express consent to be indicated separately below.

Transportation Volunteer Form

Transportation Volunteer Application

CONSENT FOR CRIMINAL BACKGROUND CHECK

GRATUITY POLICY

AUTHORIZATION TO PHOTOGRAPH/VIDEO/FILM/SOCIAL MEDIA