ACS DRIVER VOLUNTEER PROFILE FORM

Thank you for joining us in our life saving mission. Our wonderful volunteers are an integral part of our organization! We would like you to provide your contact information and complete the confidentiality agreement.

Please follow these instructions:
1.
Type your information into the forms.
a.
By checking the box and typing your name on the signature lines on page 2, 4 and 5, you can electronically sign these forms.
2.
Upload a copy of your auto insurance (insurance card or declaration page). The declaration page is the section of your auto insurance statement that shows the amount of coverage you carry. Note: You can download a copy of your insurance card from your insurance provider.
Please ensure:

a.
Your insurance coverage is up-to-date and does not expire within the next 30 days.
b.
Your name is listed under covered drivers.
3.
Please use this checklist as a reminder to send in the following items:
Completed Volunteer Profile Form
Completed Confidentiality Agreement
Once you have submitted the document, you can expect a time‐sensitive email containing a link to submit your background check information directly into our secure vendor site. If you have questions, concerns, or need assistance, please email ACS volunteer welcome form Please contact us if you have any questions. Thank you for your commitment to our mission. Your dedication is sincerely appreciated!



AMERICAN CANCER SOCIETY
Driver Volunteer Profile Form
VOLUNTEER INFORMATION
Address

Do you speak any languages other than English? If so, please list them. By providing the following demographic information, you’ll help the American Cancer Society maintain a diverse volunteer population so that we can provide the highest quality services to all patients, caregivers and survivors and reach communities at a greater risk for cancer. All information is kept strictly confidential and is optional to complete.
By providing the following demographic information, you’ll help the American Cancer Society maintain a diverse volunteer population so that we can provide the highest quality services to all patients, caregivers and survivors and reach communities at a greater risk for cancer. All information is kept strictly confidential and is optional to complete.



DRIVING HISTORY



DRIVER AUTO INSURANCE INFORMATION
Motor vehicle insurance information
Drop your insurance card here or select the file



AUTHORIZATION
All volunteers operating personal vehicles (not owned or leased by the American Cancer Society) for the business of the Society become an additional insured under the Society’s auto liability policy, but only: • In excess of the volunteer’s personal auto liability coverage and policy limits • To the extent of bodily injuries to third parties and/or physical damage to third-party vehicles or property of others where the Society is legally liable The American Cancer Society automobile insurance policy does not cover bodily injury to the volunteer or physical damage to the volunteer’s vehicle. The volunteer is required to maintain minimum required auto liability limits as mandated by the state in which the volunteer drives. However, the Society recommends that volunteers: • Maintain third-party liability limits of at least $100,000 per person bodily injury, $300,000 per accident, and $100,000 property damage • Add uninsured/underinsured motorists’ coverage to their policy • Obtain physical damage coverage for their vehicle • Maintain personal medical insurance or, through their auto policy, purchase medical payments coverage or personal injury protection (as required by no-fault states) to ensure bodily injury protection for themselves Please include a copy of your auto liability coverage (declaration page of your policy or insurance card) with your completed application. These minimum requirements are necessary to ensure that drivers are legally eligible to operate a vehicle and to minimize liability to the volunteer and the Road To Recovery program. Further detail can be found in the Road To Recovery manual. I hereby apply to serve as a volunteer driver for the American Cancer Society, Inc. (“ACS”). I agree to comply with policies and procedures of the American Cancer Society’s transportation program, copies of which have been delivered to me prior to the commencement of my volunteer service. I represent and warrant that I have read, and understand, the above-referenced policies and procedures related to ACS’ transportation program, and further agree that it is my responsibility to know and abide by all traffic laws and rules of the road applicable in my driving area. I agree that as part of the recertification process, I will be expected to complete a Motor Vehicle Record check every 2 years and a full Criminal Background Check every 4 years, during my tenure as a Road to Recovery driver. I agree to self-report any criminal and/or traffic infractions that occur during my time as an American Cancer Society volunteer by emailing ACS Background Check Reservation of Right of Refusal: I realize that ACS, in its sole discretion, reserves the right to lawfully decline and/or refuse the services of any potential volunteer at any time. The American Cancer Society, Inc. and its chartered Regions (collectively the “Society”) are committed to maintaining the highest level of confidentiality regarding the constituent information that we collect, use, maintain, and disclose. This privacy standard protects the privacy of constituent information in accordance with federal and state privacy laws, the Society’s contractual obligations, and our constituents’ expectations of privacy.



American Cancer Society - Confidentiality Agreement
I understand that the American Cancer Society, Inc. has a legal and ethical responsibility to maintain the privacy of its employees, donors, volunteers and recipients of Society services (“constituents”), including obligations to protect the confidentiality of constituent’s medical information and identity and to safeguard the organization’s other confidential information including donor information, and information concerning Society business practices and intellectual property. As a condition of my participation with the Society, I understand that I must sign and comply with the provisions of this agreement. I agree to protect all Society confidential information (as defined below) during and after participation with the Society, and I agree that I will not use (other than for Society purposes) or disclose any Society confidential information. For purposes of this agreement, “Society confidential information” shall mean any personal health information of Society constituents and any and all technical, business, and other information of the Society or any affiliate of the Society which derives value, economic or otherwise, actual or potential, from not being generally known to the public or other persons who can obtain value from its use or disclosure (other than the party disclosing such information and its affiliates), including without limitation, technical or nontechnical data, compositions, devices, methods, techniques, drawings, inventions, processes, financial data, financial plans, product plans, donor lists, lists of information concerning actual or potential donors or suppliers, and information regarding the strategies, business plans and/or operations, methods and marketing strategies of the Society or any affiliate of the Society. Society confidential information includes information disclosed or owned by third parties (including information of any affiliate of the Society) that is treated by either the Society as confidential or which it is required to treat as confidential, whether such obligation is contractual or arises by operation of law. For purposes of this agreement, Society confidential information shall not include confidential business information that does not constitute a trade secret under applicable law after the third anniversary of the termination of participation with the Society, but will remain subject to any other limitation of use or disclosure under any other agreement, applicable law or otherwise; provided, further, that such obligations hereunder shall continue infinitely with respect to confidential business information that constitutes a trade secret under applicable law and personal health information of Society constituents. I agree that I will not reproduce Society confidential information except upon the written authorization of a Society department head, and will not remove any copy or sample of Society confidential information from the premises of the Society without such authorization. I agree to keep confidential any personal access codes, user identification, and access keys or passwords used to access computer systems or other equipment unless authorized by a department head. Upon termination of my participation, I agree to immediately return all property, if any, (including computers, phones, keys, documents, identification badges, etc.) to the Society.
, have read and understand this agreement and agree to abide by the terms above. I understand that failure to do so will be treated as any other