VOLUNTEER APPLICATION

CONFIDENTIAL INFORMATION

Name:
Address:
City:
State:
Zip:
Phone:
Email Address:
Date Of Birth: " />
Gender: Male Female
Transportation Status: Own/Drive Own Car
Public Transportation
Depend on Friend/Relative
Languages Spoken:
(check all which apply)
EnglishSpanishFrench
HebrewChineseJapanese
KoreanRussianNative American Dialect
GermanThaiItalian
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Emergency Contact:
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TransportationTelephone OutreachNewsletter Distribution

Insurance information for volunteer drivers only.

Drivers License #: (Copy of D.L. Required)
State:
Expires:
Limitations on License:
Automobile Insurance Carrier:
Expires:
The Board of Directors for Desert Samaritans for the Elderly requires volunteers who operate their own private vehicles or Desert Samaritans' vehicles to provide the following minimum vehicle liability insurance coverage:

A. $15,000/$30,000 for bodily injury or death
B. $5,000 for property damage

I hereby certify that I have reviewed, and understand, the requirements and/or limitations, included in the insurance information provided above.

I hereby certify that I now maintain the minimum liability insurance coverage, as required by the Board of Directors, I further certify that I will continue to maintain this coverage for as long as I am a volunteer with Desert Samaritans for the Elderly and drive my private vehicle or a Desert Samaritans' vehicle. I further certify that I now have and will continue to maintain a current Driver's License issued by the State of California.

For office use only.

Approved to drive Desert Samaritans' Vehicle

DISCLAIMER
Volunteer workers are not covered by workers compensation insurance or by Desert Samaritans insurance for injury or accident arising out of volunteer service.

I have read and understand the foregoing notice. In addition, I understand that as a volunteer for Desert Samaritans for the Elderly I will not accept gifts or services from those I serve as a result of the performance of my duties as a volunteer. I further understand all information I obtain from those I serve is of a confidential nature and is not to be divulged outside the confines of Desert Samaritans. As well, I understand Desert Samaritans for the Elderly has the right to accept my services as a volunteer or to revoke them at any time.
 

 PLEASE PRINT OUT THIS FORM AND MAIL IT TO:
DESERT SAMARITANS FOR THE ELDERLY
P.O. BOX 10967
PALM DESERT, CA 92255