Safety Guidelines for Secondary Interschool Athletics in Alberta

Continued from previous page
Have you been convicted of an offense under the Traffic Safety Act or for any motor vehicle-related
offence under the Criminal Code during the last three years? Yes No
If yes, please provide details:____________________________________________________________
___________________________________________________________________________________
___________________________________________________________________________________
I hereby declare that I have read and understand the information contained on this form.
_____________________________ __________________________ _______________
Volunteer Driver’s Signature Vehicle Owner’s Signature Date
Authorization to Release Driver’s Abstract
Driver’s Name (in full) ________________________________________________________________
Date of Birth _________________________________
Driver’s Address _________________________________________ City __________________
Postal Code ____________ Home Phone _____________ Business Phone _________________
Driver’s License # ________________________ Activity _________ Expiry Date ___________
Volunteer Staff _______ Volunteer Parent _______
Vehicle Seating Capacity (not counting the driver):_______
Type of Vehicle used ______________ Make _______________________ Model ____________
Name of company you are insured with
________________________________________________________
Company Policy # __________________________________ Expiry Date __________________
I, the undersigned, authorize release of my Driver’s Abstract to the School Board and/or its Insurance
Agents.
_______________________________________________________ ______________
Volunteer Driver’s Signature
Date
FOR OFFICE USE ONLY
I accept the above named individual as an authorized volunteer driver for the _________ school year for
the purpose of ___________________________________________________________________.
Signature of Principal/Designate: ____________________________ Date: ___________________
78
Safety Guidelines for Secondary Interschool Athletics in Alberta - February 2012