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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