Name *

First Name

Last Name

Date of Birth *

MM

DD

YYYY

Street Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Phone Number *

(###)

###

####

Emergency Contact *

First Name

Last Name

Emergency Contact Phone *

(###)

###

####

I would like to be a: *

please select all that apply

Regular Route Driver (same route, same day each week)

Substitute Driver (willing to drive most routes to fill in as needed)

Holiday Driver (Thanksgiving, Christmas, etc.)

Shuttle Driver (Scottsville)

Shuttle Driver (Crozet)

Meal Packer (must be vaccinated)

What days of the week are you available/ interested in volunteering? *

please select all that apply

Monday

Tuesday

Wednesday

Thursday

Friday

Reference #1 (non relative) *

First Name

Last Name

Reference Phone *

(###)

###

####

Reference #2 (non relative) *

First Name

Last Name

Reference Phone *

(###)

###

####

Have you been convicted of a motor vehicle violation? *

Yes

No

Have you been convicted of a criminal violation? *

Yes

No

Are you currently under investigation for any felony charges? *

Yes

No

Is this court appointed community service? *

Yes

No