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Bethany Lutheran Church Long Beach, CA 90808

USE OF PERSONAL AUTOMOBILE FORM

September 1, 2018-August 31, 2019 Thank you for volunteering to provide transportation for our planned outing. *Please PRINT:

Name ________________________________________

Birth date: ____/____/________

Home Address:

Contact Phone Numbers:

________________________________

Home: (______) _________________

________________________________

Cell:

Driver’s License No. _________________________ YES ___ ___ ___ ___ ___

NO ___ ___ ___ ___ ___

(______) _________________

Expiration Date________________

I am at least 25 years old. I am aware of my responsibilities as a careful driver. I have a valid California Driver’s License. Every person in my vehicle will be wearing a seat belt. I have proper and current auto insurance coverage.

Description of Vehicle Vehicle License No.________________________ Year ______________

Make_______________

Color______________

I have seatbelts* for ______ people in my vehicle. *Not including the driver.

Insurance Information - *Please make a copy of insurance card and submit with this form. Insurance Company_________________________

Policy No______________________

Expiration Date______________________ Driving Restrictions____________________________________________________________ Please Note:  For insurance purposes, it is important to drive directly to the destination and directly back to the church. Please do not make any extra stops at drive-throughs, etc.  Please do not purchase food or drinks (other than water) for the people in your group unless directed to do so by the event leader. I certify the above information is correct and the insurance coverage is in force. I understand I must have liability coverage in force and agree to advice Bethany Lutheran Church in writing, of any changes in the above information. I further certify that the above vehicle is mechanically safe. I waive and forever release and discharge Bethany Lutheran Church, volunteers, and employees from all liability, claims, loss, cost or expense arising from attributable youth events.

_________________________________ Driver’s Signature Revised 8/1/18

___________________________ Date