Church of St. William the Abbot
2000 Jackson Avenue, Seaford, NY 11783
Driver/Home Registration Complete only where applicable.
The purpose of this form is to provide information concerning drivers, vehicles, and homes used for ministry purposes. Volunteer Minister
Name
____________________________________________________________
Address
__________________________________________________________________
Street, city, state, zip
New York State Drivers Lic.#: _________________________________
Home Phone: ___________________________________
Vehicle:
Vehicle to be used by Volunteer for Ministry
Year: ______________ Make: _______________________________ Model: _____________
Do you own vehicle? Yes o No o
Insurer: ______________________________________________________________
List and describe serious accidents or moving violations in the past 5 years.
I agree that I will not allow smoking when children are present in my vehicle.
Please attach a copy of your driver’s license & insurance ID Card to this form.
Continued on next page
Driver/Home Registration CONTINUED
Home/Premises: Address to be used for ministry
Address
__________________________________________________________________
Street, city, state, zip
Do you: Own o Rent o ?
Insurer: ________________________________________________________________________________
Affirmations: (Please place your initials after each statement if “True.” All statements not affirmed must be fully explained below.)
a. I am not aware of any conditions within my household that would
�
cause concern
or harm to someone entrusted to my care. ________
b. I certify that I am currently licensed to drive by the State of New York. _______________
� I will require all passengers in my vehicle to wear seatbelts. ________________
�
c. I agree that I will not allow smoking when children are present in my home. _________
Explanations: (Please use this space to provide additional information.)
Signature
_______________________________________ Date _________________ 