Christ Church

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Christ Church Christiana Hundred P. O. Box 3510, Greenville Wilmington, Delaware 19807-0510

TRANSPORTING CHILDREN & YOUTH IN A MOTOR VEHICLE All people who will transport children/youth within the scope of a church program are to complete this form. Completed forms should be kept on file in a secure place and should be updated regularly. Attached to this form should be copies of: Current Driver’s License Proof of Insurance (insurance card) Current Vehicle Registration Name:______________________________________________________________________________________ Address:____________________________________________________________________________________ Telephone: (home)________________________________

(work)__________________________________

Make, Model, & Year of Your Vehicle:______________________________________________________________ Is your vehicle in good repair and equipped with safety restraints (including those for infants and young children if you will be transporting them)?___________________________________________________________________ If there is another vehicle you might use in the course of transporting children/youth, please describe it in the same way:________________________________________________________________________________________ Have you ever had a Driver’s License revoked or suspended? If so, give details:____________________________ ____________________________________________________________________________________________ Have you ever been convicted of Driving Under the Influence?__________________________________________ Have you ever been convicted of any traffic offense in the last five years?_________________________________ If yes, give details:_____________________________________________________________________________ In transporting children/youth, I agree to: • • •

Obey all traffic regulations including speed limits and safety restraint requirements Transport only the number of persons my vehicle is equipped to carry Drive only when I am not under the influence of alcohol or other intoxicating drugs

Signed:_____________________________________________________________________________________ Date:__________________________________________ Phone (302) 655-3379 Fax (302) 655-2259 www.christchurchde.org