2017 Volunteer Application Form

Email:

Application Procedure

Complete and sign this application. Provide a scan or colour photocopy of the front and back of your driver’s licence.

Forward all documentation by email to:

For further information contact: Program Coordinator – Jodie Hogg at

Press the “Tab” key to move to the next cell

First Name / Middle Initial / Last Name / Sex
M F
Street Number / Street / Apt./Unit / City / Postal Code
Home Phone / Cell Phone / Work Phone / Ext. / Date of Birth (yy/mm/dd)
Email Address / Group / Company organizing your participation in CDDA (if applicable)
Driver’s Licence Number / Licence Expiry / Do you drive Standard?
Yes No

Nights Available During the 2017 CDDA Chatham-Kent Campaign

CDDA Chatham-Kent operates from November 24th to December 31st. Please mark an “X” in the box beside the dates that you are available during the campaign. You may add dates during the campaign if you find you have more availability later. The program hours will be 9pm to 3am on all nights except New Year’s Eve where hours will be 9pm to 4am.

Week #1 / Week #2 / Week #3 / Week #4 / Week #5 / Week #6
Fri. Nov. 24 / Fri. Dec. 1 / Fri. Dec. 8 / Fri. Dec. 15 / Fri. Dec. 22 / Fri. Dec 29
Sat. Nov. 25 / Sat. Dec. 2 / Sat. Dec. 3 / Sat. Dec. 16 / Sat. Dec. 23 / Sat. Dec. 30
Sat. Dec. 31

Would you be interested in being contacted to work other Community Events throughout the year? Yes No

Volunteer Duties (Check all duties that you are interested in)

Check / Title / Description
Escort Driver / Escorts the driver and navigator to and from each client destination. Must be 1) 18 yrs. of age, 2) have a valid driver’s licence, 3) have valid automobile insurance
Driver / Drives the client’s vehicle. Checks with the client to see insurance documentation. Ensures vehicle is fit for driving. Must be 1) 21 yrs. of age, 2) have a valid driver’s licence, 3) have valid automobile insurance
Navigator / Rides with the driver in the client’s vehicle. Communicates with the Dispatcher by cell phone to coordinate the next pick-up location or to report any incidents. Completes the Dispatch Forms; recording times, number of passengers, amount of donation, etc. Submits documentation at the end of the shift.
Telephone Operator / Receives calls from clients. Enters the data onto Dispatch Forms. Co-ordinates calls with the Dispatcher. Must be 19 yrs. of age.

► I certify that the information provided is accurate and complete.

By checking this box I consent to the use of my name, image, and likeness in the form of photographs or videos for promotional purposes by Community Designated Drivers Association, its partners, affiliates, agents, employees, representatives, licensees, and assigns, without notification or compensation

By checking this box I consent to Community Designated Drivers Association – Chatham-Kent conducting a criminal record check

Date:

Signature:

If submitting your application electronically, please type your name

in the signature box, to agree to application terms.