FREEMASONS VOLUNTEER DRIVER PROGRAM APPLICATION

The Most Worshipful Grand Lodge of Ancient Free and Accepted Masons of British Columbia and Yukon (Grand Lodge) is
committed to protecting the privacy of personal information in our possession or under our control in accordance with the Personal
Information Protection Act (PIPA). PIPA regulates the way we collect, use, keep, secure and disclose personal information. The
personal information collected on this form will be used by the volunteer resources team to identify an appropriate volunteer
placement and to provide you with appropriate support and recognition. This information will be stored in a locked cabinet and if
you become a volunteer it will be entered into our secure electronic database to track your volunteer activities. The Grand Lodge
values the trust of our donors, volunteers, clients, participants and staff. We recognize that maintaining this trust requires
accountability and transparency in handling personal information. For further information call 604-736-8941

As a Volunteer I am interested in being a,

Driver: Yes ; Computer Operator: Yes ; Dispatcher: Yes

Name: (Surname)_________________________________ (Given Name) ___________________________________

Hm Phn: _______________________________ Yes Cell Phn: ______________________________ TEXT: Yes
Email: _________________________________________________ _ Yes

(PLS Check best methods of contact)

Address:______________________________________________________________________________ ________
Occupation: _____________________________________ Employer: ____________________________________
EMERGENCY CONTACT
(name)

(phone)

(relationship)

REFERENCES
(name)

(relationship)

(phone)

(name)

(relationship)

(phone)

I authorize the FCCP Management to obtain references from the individuals listed above.

Yes

Please mark preferred shifts(s) Mon - am pm : Tue - am pm : Wed am pm : Thu - am pm : Fri am pm

*DRIVERS ABSTRACT ATTACHED** Yes

*ICBC CLAIMS HISTORY ATTACHED Yes

*CCS/FCCP VOLUNTEER AGREEMENT SIGNED SHEET ATTACHED

Yes

* I have read the CCS/FCCP VOLUNTEER AGREEMENT. I understand them and agree to abide them at all times. Yes
* I hereby apply to become a Volunteer Driver for the Freemasons Cancer Car Program. I understand that the Freemasons Cancer Car
* Program works in support with the Canadian Cancer Society. If accepted. I agree to participate in initial and ongoing training and to comply
with all program requirements and guidelines. I understand that I am responsible for all MV violations, parking tickets, any liabilities to my
vehicle or my person that arise from my volunteer assignment.
Yes
*I understand that Volunteer Drivers who use there own vehicles must carry a minimum of $5,000,000.00, 3RD Party Legal Liability Insurance
and that proof of insurance must be carried in the vehicle at all times. Copy attached Yes N/A
* I plan to use my vehicle and have attached/provided a copy of auto insurance.

*I have the use of a well maintained automobile: N/A

Yes N/A

_
(year)

_
(make)

(model)

By signing and submitting this Volunteer Application, I acknowledge the information I provided on this form is true and accurate.

_____________________________________________________

_________________________________________

Signature

Date

**Abstracts available @ ICBC 604-661-2800 or http://www.icbc.com/driver-licensing/getting-licensed/Pages/Your-driving-record.aspx

CANCER CAR PROGRAM DISPATCH OR REGIONAL OFFICE INTERNAL USE

Date
Initial
Interviewed by
Reference Checks
Driver Abstract Attached
ICBC Claims History
Insurance Attached
Placement
Orientation
Signed Volunteer Agreement Sheet
Freemason Cancer Car Project Dispatch or Regional Office

Date

Initial

Follow up
Start Date
Finish Date
Reason for Leaving

Volunteer Number: __________________