I authorize all information provided in this application to be released to Faith in Action Caregivers for the purpose of considering my participation as a volunteer driver in the LIVESTRONG Cancer Transportation Program. I confirm that all of the information I have provided is true and correct to the best of my knowledge. I give my consent for Faith in Action Caregivers and the LIVESTRONG Foundation to contact my references. I agree to indemnify and hold harmless the LIVESTRONG Foundation, Faith in Action Caregivers, or any other partner in this program from and against all losses, claims, damages, and liabilities to which any partner to the program may become subject arising out of or in connection with the LIVESTRONG Cancer Transportation Program. I understand that a criminal background check and a driving record check will be conducted. If volunteering to drive, I agree that I am responsible for maintaining a valid driver's license and current liability insurance on my vehicle and am obligated to notify Faith in Action Caregivers of change in status of either. I understand that giving false information or withholding information relevant to health conditions that would affect the ability to drive in a safe manner will be grounds for dismissal. All information is considered confidential by both the LIVESTRONG Foundation and Faith in Action Caregivers.
I have read and understood the statements above.*