Thank you for your interest in volunteering with Senior Services. Please complete this application form if you are interested in becoming a Senior Services of Southwest Michigan volunteer. Once you complete the form, click the Continue button at the bottom.

Your Information


Additional Information


Emergency Contacts

Please enter the name and contact information of your emergency contact person(s).


Insurance

Please answer yes or no below.


Do you carry, on the personal vehicles you drive for volunteering, at least the required minimum basic coverage as required by the State of MI or the state which issued your registration/license?


Driving Records

We collect this information in compliance with state and federal law and due to the nature of our volunteer assignments and the population we serve.


Please answer yes or no to the questions below.


Have you received any driving violations in the past two years?


Agreements and Acknowledgments

AGREEMENT TO NOTIFY OF DRIVING EVENTS:
I agree to immediately inform the Volunteer Services Manager & my supervisor if my driver’s license is suspended or revoked, or if I have Driving While Intoxicated or Impaired (alcohol or drugs) charges pending. I must also notify the Volunteer Services Manager & my supervisor if my personal auto insurance is cancelled or not renewed. These notifications are required even if the offenses are not related to my volunteer work for Senior Services. This information will not be released to unauthorized persons. Traffic Laws I agree to follow all traffic laws, observe speed limits, and operate vehicles in a safe manner. Seat Belt Usage I agree to transport persons only in the passenger seats equipped with appropriate seat belts. I agree to require seat belt usage at all times. This rule does not apply in buses that are not outfitted with seat belts. Safe Vehicles I agree to transport persons only in vehicles that are in safe operating condition.

ACKNOWLEDGMENT
By signing below, I acknowledge that I have truthfully and accurately responded. I agree and understand that: 1. I am authorizing a check of references supplied by me and confidential criminal history checks to be conducted on me by Senior Services whether I am a current volunteer or an applicant. 2. If I utilize my personal vehicle in the performance of my volunteer duties, my driving record will be requested. 3. I allow Senior Services to conduct confidential criminal history and driving record checks. I will provide a copy of my driver’s license and/or government issued identification card in person at my volunteer orientation. 4. I will notify my supervisor and Volunteer Services Manager if any of the Auto Safety Certification driving events listed above occurs.