Name *

First Name

Last Name

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Phone

(###)

###

####

Cell Phone

(###)

###

####

How do you want to receive ride reminders? *

I prefer emails

I prefer texts

Are you willing/able to transport passengers with medical equipment (i.e. an oxygen tank or walker?) *

Yes

No

Are you willing/able to transport a passenger with a seeing eye dog/service animal? *

Yes

No

Are you willing/able to allow a passenger to install an infant/child car seat in your vehicle? *

Yes

No

Are you willing/able to allow a passenger to install an infant/child car seat in your vehicle? *

TASC Occasionally provides rides to a grandparent/grandchild or disabled parent with their child.

Yes

No

Are you interested in learning more about serving as a volunteer driver for TASC's wheelchair accessible minivan? *

Yes

No

Do you spend part of the year living in another location? *

Yes

No

Emergency Contact Information *

Name

First Name

Last Name

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Phone

(###)

###

####

Cell Phone

(###)

###

####

This application warrants a criminal history background check, and verification of my motor vehicle record as authorized by my signature below. Forms will be provided at orientation. *

By accepting these terms, I authorize Transportation Assistance for Seacoast Citizens (TASC) to obtain, at its sole discretion and expense, my driving record, including all Department of Safety actions that have taken place regarding the driver's license I now hold, have held, or in the future may obtain. I also authorizes TASC to conduct a criminal history background check from the source of its choice. I agree to carry current automobile liability insurance while I am a Transportation Assistance for Seacoast Citizens volunteer. I further agree to any other conditions described herein. This release continues in effect as long as I continue to serve as a TASC volunteer.

I understand

Date

MM

DD

YYYY