Final Copy

2014-15
Pat Carlson, Transportation Coordinator
Harvey Region Dial-a-Ride
2014-15
Harvey Region Dial-a-Ride Application Kit
for Drivers and Riders
Harvey Region Dial-a-Ride
Internal Forms-
1
For internal use only: Reviewed by __________________________ Date _____________
Accepted
Denied

CONFIRMATION OF INSURANCE COVERAGE FOR VOLUNTEER DRIVER
To be signed by Insurance agent for the Volunteer driver


This is to confirm our awareness that is a Volunteer Driver with
the Harvey Region Dial-a-Ride, a non-profit organization that works to meet the transportation needs of
people in our community. We understand that the person named above will be providing occasional
driving services using his/her own personal vehicle within the Harvey Region comprising the local service
district of Manors Sutton, New Brunswick. He/she will be serving as a volunteer and will receive
compensation only for the purpose of recovering fuel expenses.


This is to confirm that the person named above carries at least two million dollars of insurance liability
coverage.
Volunteer Driver:

First Name Last Name:
Address: Postal Code:

Telephone: E-Mail:

Name of Insurance Company:

Address: Postal Code:

Telephone: E-Mail:

Policy Number:

Name of Agent (please print): _________________________________________

Signature of Agent: _____________________________ Date: ___________/ 20





Harvey Region Dial-a-Ride
Internal Forms-
2
For internal use only: Reviewed by __________________________ Date _____________
Accepted
Denied


Confidentiality Agreement and Hold Harmless Agreement

I, ___________________________________, agree to Hold Harmless the agency and/or committee
members of the Harvey Region Diala- Ride service for any unforeseen event or circumstance that
may bring some misfortune to me. I am acting as a volunteer with only small honorarium being paid
towards fuel cost.

I, ________________________________ further agree to maintain polite and courteous behaviour
while driving my vehicle and will hood in confidence all business overheard or spoken directly to me,
unless to do so would bring harm to another or break a law.

Note:
Right to REFUSAL OF SERVICE

Volunteer drivers shall reserve the right to refuse to provide transportation services that are deemed
dangerous or offensive. Such items might be, but are not limited to; abuse of drugs or alcohol, poor
hygiene, or other socially unacceptable behaviour.

Signed ___________________________, Date ____________/20___

Witness __________________________, Date ___________/20







Harvey Region Dial-a-Ride
Internal Forms-
3
For internal use only: Reviewed by __________________________ Date _____________
Accepted
Denied
Application to become a Member
Membership and COSTS FOR SERVICE
To help defray the costs for transportation, a nominal fee for membership will be offered for those
wishing to support the program. Membership shall be offered at a flat fee of $60.00 a year.
Membership allows for a reduced per Km charge of $.17 cents, with a $5.00 minimum charge per trip.
Non-members will be charged $.25 cents per Km with a minimum of $7.00 per trip.
If you have any questions about this form please contact us at our information line: 366-3344

First Name:* ____________________________
Last Name:* ____________________________
Mailing Address:* _____________________________, ____________________, NB
Postal Code:* __________________
Civic Address (If Different from Mailing Address): ______________________________
Phone Number:* __(506)_________-______________
Email Address (If you have one) _____________________________________
Number of Children in Household (If under 18): __________
Were You Referred by Someone?
Yes , If yes, by whom? ________________________________
No
Do you own a vehicle?
Yes
No
Do you have a disability?
If yes, please describe in detail the nature of your disability and any assistance that you might require
because of your disability.
Yes
No
Harvey Region Dial-a-Ride
Internal Forms-
4
For internal use only: Reviewed by __________________________ Date _____________
Accepted
Denied
Are you 65 years or older?
Yes
No

If yes, please note that attendants travel for fare. It is the responsibility of the member to provide the
attendant, and the attendant must be present at the time of the pick-up and return.
Yes
No
What will be your main purpose for using our service?
Medical
Employment
Job Training
Education
Household Errands
Family Social or Recreational
Other
If other please list: __________________, _____________________, __________________________
Please list One Person as a Reference: (cannot be a family member)____________________________
Phone Number of Reference:*
In case of emergency - contact* ________________________________
Phone: ____________________ Cell: ____________________________
Relation to member? _______________________________
I have read the rules and regulations set forth by the Harvey Region Dial-a-Ride
and I agree to abide by these rules and regulations. I declare that I do not have access to affordable
and/or accessible transportation.
Yes
No
Signed by me: _____________________________ on _______________/___/20__
Harvey Region Dial-a-Ride
Internal Forms-
5
For internal use only: Reviewed by __________________________ Date _____________
Accepted
Denied

Application to become a Volunteer Driver

First Name:* _______________________________
Last Name:* _______________________________
Mailing Address:* ____________________________, _____________________, NB
Postal Code:* _______________________
Name of community you wish to serve:*______________________________________
Phone Number:* __________________________________
Email Address (If you have one) _________________________________________
Most reliable way to contact you for bookings:* ____________________________
Application to become a volunteer driver
Have my criminal record check/vulnerable sector check done and passed in
Signed the hold harmless and confidentiality agreement
Driving abstract done and handed in
Insurance document signed by my agent
Read the policies and agree to adhere to all
I have been advised that I have the right to refuse should a situation warrant it
I agree to attend a defensive driving course, now and/or later if so required
Please check all items as they are done.

Signed _____________________________ Date ______ /20

Harvey Region Dial-a-Ride
Internal Forms-
6
For internal use only: Reviewed by __________________________ Date _____________
Accepted
Denied
Drivers Log Name of Driver ____________________________________
Max # of Stops in one trip is set at three. (3)
Name of Rider __________________________________________ Full fare________ Fare______
Date Riders
Initials
Pick-up Address Destination # 1 Destination # 2 or 3 Total
Kms
Paid
drivers
initials





Name of Rider __________________________________________ Full fare________ Fare______
Date Riders
Initials
Pick-up Address Destination # 1 Destination # 2 or 3 Total
Kms
Paid
drivers
initials





Comments fill in only is necessary for the committee to discuss any concerns. Please give date and
specifics of concern.
Date _________________
Concern/Incident
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
Signature ___________________________