Transportation Program Volunteer Application

Thank You!

Thank you for your application. A representative will contact you shortly.

Name First Name* Last Name*

Address Address* State* Country Zip Code* Neighborhood County*

Contact Information Best Phone Number To Reach You* Alternate Phone Number E-mail*

Personal Information Gender Date of Birth* Occupation

Driver Information Have you ever been convicted of a violation, traffic or otherwise?* If yes, please explain Do you have any physical conditions that may limit your activities or ability to drive safely?* If yes, please explain List anyone that will be with you in the car during volunteer rides

Availability

Please indicate your volunteer day/time preferences and availability below.

Please indicate below how often you intend to provide volunteer transportation.*

Per Month	Per Week
1 or 2 times per month	1 time per week	4 times per week
3 or 4 times per month	2 times per week	5 times per week
More than 5 times per month	3 times per week	As often as possible

Are you available on short notice? (Less than one day)

Background Briefly describe your experience with cancer and/or volunteering in the cancer community Other volunteer experience Other information that will help us make a good match (interests, hobbies, skills, etc.) Languages other than English in which you are fluent Organizational Affiliation (Optional)

Vehicle Vehicle Make/Model Vehicle Year

Emergency Contact Name Relationship Home Phone Cell or Work Phone

References: Please list two references we may contact who are not immediate family.

Reference 1 Name Relationship Address Home Phone Cell or Work Phone

Reference 2 Name Relationship Address Home Phone Cell or Work Phone

I authorize all information provided in this application to be released to Faith in Action Caregivers for the purpose of considering my participation as a volunteer driver in the LIVESTRONG Cancer Transportation Program. I confirm that all of the information I have provided is true and correct to the best of my knowledge. I give my consent for Faith in Action Caregivers and the Lance Armstrong Foundation to contact my references. I agree to indemnify and hold harmless the Lance Armstrong Foundation, Faith in Action Caregivers, or any other partner in this program from and against all losses, claims, damages, and liabilities to which any partner to the program may become subject arising out of or in connection with the LIVESTRONG Cancer Transportation Program. I understand that a criminal background check and a driving record check will be conducted. If volunteering to drive, I agree that I am responsible for maintaining a valid driver's license and current liability insurance on my vehicle and am obligated to notify Faith in Action Caregivers of change in status of either. I understand that giving false information or withholding information relevant to health conditions that would affect the ability to drive in a safe manner will be grounds for dismissal. All information is considered confidential by both the Lance Armstrong Foundation and Faith in Action Caregivers.

I have read and understood the statements above.*

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