Driver Declaration Form - Policy • Berwick Church of Christ Inc.

Driver Declaration Form - Policy

As part of the Transport Safety Policy, all Drivers with responsibility for providing transport during a program are required to complete this Form.

The Driver's Declaration Form is to be signed every three (3) years or when any details on this Form change, or if your licence is suspended or cancelled. All personal information recorded on this Form will be kept confidential and recorded in our Church Management System which is maintained by the Safety Contact Person.

Driver's Information

First Name *

Mobile Number *

Victorian Licence No: *

Last Name *

Email Address *

Licence Expiry Date *

Licence Type(s) Select all that are relevant. *

Give details of Restrictions on your Licence (e.g. Green 'P' Plates)

Vehicle Information

If providing a vehicle (car or boat), please provide the following details:

I will be providing a Vehicle *

Yes

Car - Make and Model *

Car - Insurance Company and Policy Number *

Car - Registation No. *

I will be providing a Vessel *

Yes

Boat/PWC - Make & Model *

Boat/PWC - Insurance Company & Policy No. *

Boat/PWC - Registration No. *

Driver's Declaration

As the named driver on this form, I declare that:

I have read and understood the Transport Safety Policy.
I will drive carefully and follow all Victorian Road Laws and/or Victorian Marine Safety Regulations.
I will ensure that all passengers wear a seat belt when in a motor vehicle
I will ensure that all passengers wear a life jacket as required by the Victorian Marine Safety Regulations when in a boat/PWC.
I will provide a registered, roadworthy and insured vehicle.
I will only use a mobile phone or inbuilt device whilst driving in accordance with the road rules.
The information provided in this form is correct and indicates my commitment to the safety and welfare of all those for whom I am responsible.

Electronic Signature *

I agree that by checking this box, I am electronically signing this declaration.

Add the date this declaration was completed. *

Alcohol & Drug Policy - Driver's Commitment

As the named driver on this form, I declare that I have read and understand the Alcohol & Drug Policy.

As a driver, for and on behalf of Berwick Church of Christ, I recognise the detrimental effects that drugs and alcohol may have on the safety of driving a vehicle or vessel and the general health and wellbeing of individuals.

I will ensure that every time I undertake driving any vehicle or vessel and in particular bus safety work, as defined under section 3 of the Bus Safety Act 2009 (Vic):

I will have no drugs or alcohol present in my blood or breath immediately before, or while undertaking driving
I will inform my treating health practitioner or pharmacist of my policy obligations when being prescribed medications.
I am not impaired by drugs or medications.

Electronic Signature *

I agree that by checking this box, I am electronically signing this commitment.

Add the date this commitment was signed on *

Copy of your Driver's Licence required

To complete the process, can you please forward a copy of your Driver's Licence (either jpg or pdf) using our secure dropbox. You will be directed to the Church's secure dropbox when you click on submit below.