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2. Name*
3. Last Name*
5. Address*
6. City*
7. Zip Code*
9. Telephone Number 1*
10. Telephone Number 2
11. Email Address*
12. Shirt Size
14. Note

    You may be disqualified in certain positions with the City of Beavercreek if the results of the criminal background check reveal a particular criminal history. 

16. Do you have a valid Ohio driver's license?

    1. Yes
    2. No
17. Have you ever had your license suspended?

    1. Yes
    2. No
18. Do you have any driving restrictions?

    1. Yes
    2. No
19. 4) Are you currently taking any medication that could impair your ability to drive a vehicle?

    1. Yes
    2. No
21. Driver's License Number
22. State
23. Expiration
25. If you answered yes to any of the questions above, please explain:
27. Van Drivers Signature

    By typing my full name and date below, I understand that prior to starting a volunteer position as a van driver, I will be drug and alcohol tested and that accepting this position requires me to follow the city’s volunteer drug-free workplace policy.

    I affirm that all information provided in this application is true and accurate.  I authorize the City of Beavercreek to complete an application verification to assist in determining my suitability as a volunteer.  I understand the background check will include, but not limited to, a criminal history and driving record.  I also acknowledge that false statements are grounds for not being accepted.

    I further understand that volunteers are not covered by workers' compensation, and I will not hold the City of Beavercreek liable for injuries while volunteering for the City.

29. Signature*
30. Date*
32. Thank you!

    Thank you for your interest in volunteering for the Beavercreek Senior Center's transportation program! A member of our team will be in touch with you shortly.

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35. 1. Receive an email copy of this form.
36. Email address

    This field is not part of the form submission.

37. Submit

* indicates a required field