9 Warwick Road, Pitstone, Beds, LU7 9FE
Tel: 01296 767261.  Email: parishclerk@pitstone.co.uk
Facebook: “Pitstone Parish Council” and “Pitstone Youth”
Twitter: @pitstone_pc    Web: www.pitstone.co.uk

PITSTONE PARISH COUNCIL

Pitstone Community Car Scheme
POLICY  CONFIRMATION AND DECLARATIONS
Name: ________________________________________________________________

I confirm that I have received, read, understood and agree to comply with all the following policies and documents:
•	Health and Safety policy
•	Lone worker and personal safety policy
•	Confidentiality policy
•	Data Protection policy
•	Equal Opportunities policy
•	Safeguarding policy
•	Mobile Phone policy
•	Complaints policy
•	Risk Assessment
•	General guidelines and information relating to drivers, vehicles and passengers
•	Do’s and Don’ts
Confidentiality Declaration

The Confidentiality Policy of the Pitstone Community Car Scheme has been explained to me.  I declare that I have read and understood it, and had the opportunity to seek clarification, and that I will operate within its boundaries.
I understand that during the course of my involvement with the car scheme I may come to be aware of personal information about users or volunteers within the organisation.  I understand that this information is of a confidential nature and agree that any such information must not be shared with any other person outside those specifically stated within the Confidentiality Policy.  I agree not to disclose any of this information without the specific consent of the person to whom the information pertains, within the guidelines of the Confidentiality Policy.
I understand that this declaration constitutes a contract between me and the Pitstone Community Car Scheme.

Personal Data Declaration

I give my consent for the Pitstone Community Car Scheme to record my personal information about me electronically and manually.

I understand my information will not be passed onto another organisation or person without my permission.

I also give permission for the car scheme to contact me via email or phone. 

I also declare that the information given in relation to my application is true and complete to the best of my knowledge and belief.

Volunteer Drivers Declaration

I wish to offer my services as a volunteer driver. I have been informed of the procedures and I understand fully what I may be asked to do.

I confirm that I hold a valid driving licence and motor insurance. I have advised my insurance company of my intention to drive on a voluntary basis. Should either my licence or insurance lapse or my licence be endorsed, I will inform the co-ordinator.

My car is taxed and has a current MoT (if required) and it will be kept in a safe and roadworthy condition. I will at all times comply with relevant legislation governing the use of motor vehicles. I undertake to inform the organising committee of any material changes to my health or any other circumstances affecting my ability to carry out voluntary driving work.

Signed_______________________________________________Date	

Please return the completed form to the scheme co-ordinator