Driver Form for ALL Adults driving YW to and from Camp as well as on Hikes

Driver Certification Form ** Young Women Girl’s Camp

Driver:

Name______________________     Date of Birth_______________________

Address________________________________          Phone No_________________

Driver’s License No_______________________ Expiration Date____________

Vehicle Information:

Name of Vehicle’s Registered Owner__________________________________

Address_______________________________________________________

Vehicle Year______________ Make____________      Color_______________

License Plate___________________          Expiration Date_____________________

Seat Capacity_____________ # Seat Belts available for Passengers__________

Insurance Information:

Insurance Carrier:________________________________________________

Policy Number______________________  Expiration Date:________________

Name of Agent____________________  Phone No__________________

Driver Certification Statement

I certify that I have not been cited for reckless driving or driving under the influence of drugs or alcohol within the past five years.

I certify that the information given above is true and correct.  I understand that if an accident occurs, my insurance coverage shall bear primary responsibility for any losses or claims for damages.

Name__________________________  Date________________________

Valid for 4 months from signing.

If any changes occur in the categories above, a new driver certification form must be completed.

Please attach a copy of your Insurance Card.