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Adult Annual Driving Chaperone Info Sheet

(REQUIRED EACH YEAR)

This form is to be completed each year, for each vehicle you may possibly drive for a youth event.

Driver

Please complete this form for each adult who might drive for a youth event for St. Michael's.

Name

First Name*

Last Name*

Address

Street 1*

Street 2

City*

State*

Zip*

Phone

Required* --

Date of Birth mm/dd/year

Required*

Driver's License #

Required*

Expiration Date of Driver's License

Required*

Vehicle(s) that will be used to transport youth

Please list all possible vehicles that you might use to transport youth for a St. Michael's event.

Name of Owner

First Name*

Last Name*

Address of Owner

Street 1*

Street 2

City*

State*

Zip*

Make & Model of Vehicle #1

Required*

Year of Vehicle #1

Required*

License Plate # for Vehicle #1

Required*

License Plate Expiration Date for Vehicle #1

Required*

Vehicle Registration Expiration Date for Vehicle #1

Required*

# of seats with functional seat belts for Vehicle #1

Required*

Make & Model of Vehicle #2

Year of Vehicle #2

License Plate # for Vehicle #2

License Plate Expiration Date for Vehicle #2

Vehicle Registration Expiration Date for Vehicle #2

# of seats with functional seat belts for Vehicle #2

Vehicle Insurance Information

	*Please note: The minimal, acceptable liability limit for privately-owned vehicles is $100,000/$300,00. (This is a standard amount found with most complete coverage polices.)
Name of Insurance Company	Required*
Insurance Policy #	Required*
Date of Policy Expiration	Required* //
Liability Limits of Policy*	Required*	*When using a privately-owned vehicle, the insurance coverage is the limit of the insurance policy covering that specific vehicle.
List of Accidents or Moving Violations in the past 5 years	Required*	In order to provide for the safety of our students or other members of the parish and those we serve, we must ask each volunteer to list all accidents or moving violations they have had in the past five years: (If this does not apply to you, please type none or n/a.)

Signature Field

"Signature" Line	Please note that as a volunteer driver, your insurance is primary.*	By typing my full name and today's date, I certify that the information given on this form is true and correct to the best of my knowledge. I understand that as a volunteer driver, I must be 21 years of age or older, possess a valid driver's license, have the proper and current license and vehicle registration, and have the required insurance coverage in effect on any vehicle used to transport students. I agree that I will refrain from using a cell phone or any other electronic device while operating my vehicle.