AUTOMOBILE DRIVING RECORD WORKSHEET Organization Name: Date Completed: Driving records for all drivers should be checked as part of the hiring process and on an annual basis thereafter to a written non-discriminating organizational policy. Please provide the following information regarding driver experience. 1. Person responsible for managing driving records: Name Title 2. Total number of power units: 3. Total number of drivers: 4. Total number of MVRS ordered: 5. drivers with type "A" violations (3 years): 6. driver with 3 or more type "B" violations (3 years): Name of person completing this form: TYPE "A" VIOLATIONS - MAJOR VIOLATION * DUI, DWI, OUI, OWI * Refusing a substance test * Driving with an open container of alcohol * Reckless driving * Hit and run * Fleeing a police officer * Racing * Driving while license is revoked or suspended * Manslaughter - by motor vehicle * Felony - death by motor vehicle TYPE "B" * Speeding * Improper lane change * Failure to yield * Failure to obey a traffic signal * Failure to obey a sign * License suspension * At fault accident Eligible drivers must: 1. Be at least 18 years old 2. Have an acceptable driving record 3. Have a valid license 4. Be familiar with the vehicles to be used or given instruction prior to driving your vehicles. 5. Have a recent criminal background check on file. The Redwoods Group P 800-463-8546 F 919-462-9727 www.redwoodsgroup.com Y_ADRW_5.08
BOYS & GIRLS CLUBS 12 & 15-PASSENGER VAN ACTION PLAN Organization Name: Plan Date: CPO/Executive Director Signature: CVO Signature: We currently have no 12- or 15-passenger vans used to transport people (some may have been converted to cargo vans) We agree that neither we nor our volunteers will rent, lease, borrow, or use any 12- or 15-passenger van to transport people in conjunction with camp programs or on camp business and that we will not accept them as gifts. We agree to announce this position to all staff, volunteers, and donors annually. -OR- No purchase, rental, lease, loan, or use of additional 12/15 passenger vans Implement vehicle safety measures provided by Redwoods - Remove any roof-racks / remove tow-balls - Remove the backseat from all 12/15 passenger vans Implement driving safety policies provided by Redwoods - Do not drive on limited access roadways - Do not exceed 45-mph maximum driving speed - Do not carry more than 10 passengers - Do not carry luggage on the roof or in a towed trailer - Keep heavy storage low, secure and ahead of the rear axle - Check tire pressures daily to conform to manufacture guidelines - Inspect van before and after every trip (inspection form attached) Implement administrative safety policies provided by Redwoods - Implement training and testing for all new drivers - Implement semi-annual update training for all van drivers ACTION GOAL DATE COMPLETION - Restrict drivers to those who are thoroughly familiar with the handling and response of a 12/15 passenger van and who have received appropriate training - Maintain at branch and association office current list of these drivers (attached) - Keep and maintain records of vehicle inspection forms Limit use of vans to local use only (outsource or use minivans on all trips requiring highway usage until all vans can be replaced by minivans, buses or mini-buses) Begin transition to buses or mini buses by replacing existing vans when necessary with buses. (By-vehicle timeline attached) Eliminate use of 12/15 passenger vans for transportation Risk Management services are provided by The Redwoods Group to assist the insured in fulfilling their responsibilities for the control of potential loss-producing situations involving their operations. The information contained is not intended as legal advice; it simply represents trends in the industry, related industries, and/or law. Laws and suggested standards are under constant review by courts, states, and trade groups. They can be vastly different in each jurisdiction. BGCs are advised to seek the services of a local personal attorney for legal advice relating to any subject addressed. The information is provided "AS IS" without warranty of any kind and The Redwoods Group, Inc. and the Redwoods Group expressly disclaims all warranties and conditions with regard to any information contained, including all implied warranties of merchantability and fitness for a particular purpose. The Redwoods Group, Inc. assumes no liability of any kind for information and data contained or for any course of action you may take in reliance thereon. INSURANCE PROGRAM FOR BGCs P 800-463-8546 F 919-462-9727 www.redwoodsgroup.com C_VAP_12.09
BOYS & GIRLS CLUBS NEW BUSINESS QUESTIONNAIRE Please complete form electronically by pressing tab key to progress to each field, or you may print form and fill in manually. Club Name FEIN # EXECUTIVE STAFF Name of CEO/CPO: Years as CEO/CPO: Total years with this Club: Prior Club: Total years with prior Club: GENERAL INFORMATION Total number of employees: Full Time: Part Time: Total number of volunteers: Total number of kids enrolled: Annual Revenue: Average Daily Attendance: PROFESSIONAL STAFF How many people work at the Club in the following capacities? Licensed/Certified Social Workers: Licensed/Certified Counselors: Registered Dieticians/Nutritionists: Employed/Contracted/Volunteer Nurses: EMTs: Staff who handle money: OPERATIONS List individual Clubs and give a brief description of activities (e.g: camp, pool, youth sports, etc.) or attach schedule) Club Name Location Address Hours of Operation Age Range of Participants Average Daily Attendance Page 1
OPERATIONS CONTINUED Check any activities available at any of your club locations: Archery Low Ropes Course Swimming Horseback Riding Skate Park Riflery Sailing/Boating Gun Range High Ropes Course Climbing Wall/Tower Trampolines Gymnastics Ziplines Other Please describe any abuse/molestation incidents and/or claims over the past 5 years: CAMPS Total number of off-site day camps: Address Average Daily Attendance # of Days Camp is Open Total number of overnight camps: Address Average Daily Attendance # of Days Camp is Open Page 2
CAMPS CONTINUED Check any activities available at any of your camp locations: Archery Low Ropes Course Swimming Horseback Riding Skate Park Riflery Sailing Gun Range High Ropes Course Climbing Wall/Tower Trampolines Golf Carts White Water Rafting Kayaking Canoeing Adventure Programs boats in use: Sailboats under 21 feet: Motorboats under 26 hp: Sailboats 21 feet+ : Motorboats 26 hp+ : saddle animals Club owns: saddle animals Club leases: dams located on the insured property: FIELD TRIPS field trips taken each year: Field Trip Location Participants Overnight Stay? (Yes or No) Page 3
SWIMMING POOLS & WATERFRONTS Total number of pools/outside bodies of water used for swimming at your clubs/camps: Club/Camp Name Indoor Pools Outdoor Pools Bodies of Water Days Used Each Week Please check any and all of the features available at the above listed pools/bodies of water: Waterslide (above 15 ft) Lazy River Current Channel Vortex Pool Spray Ground Diving Board Splash Pad Flow-Rider Public Access Total number of pools/outside bodies of water used by your clubs/camps: Club/Camp Name Indoor Pools Outdoor Pools Bodies of Water Days Used Each Week MANAGEMENT CONTROLS Are Criminal Background Checks performed on all staff working directly with children prior to being hired? Are all staff members trained on how to avoid abuse allegations? If Yes: Upon Hire? and/or during employment? How often? Is there a policy prohibiting off-site baby-sitting of participants? Except with written permission of the Executive Director? Page 4
MANAGEMENT CONTROLS CONTINUED Are children separated by age during program activities? Please describe check-in/check-out procedures below: COMPUTER LAB Does your Club have a formalized policy for computer usage? Are Club participants required to sign a code of conduct for computer use? Are all computers and other electronic equipment monitored regularly for inappropriate use? Are appropriate parental/website controls established for all computer and electronic equipment? AMERICANS WITH DISABILITIES ACT CONTROLS Has your Club (including all locations/operations) had a formal ADA audit by a qualified consultant? If yes, were formal recommendations submitted? Has your Club (including all locations/operations) received any written ADA related complaints from members, patrons, guests, and/or employees in the past 5 years? Is a record kept of such complaints and their resolutions? Have your employees and volunteers been trained to report any non-written ADA related complaints? Is a record kept of such reports and their resolutions? How often does your Club (including all locations/operations) review current ADA related policies and procedures, facility access, job descriptions, job accommodation processes and training for managers and staff: Page 5
SOCIAL PROGRAMS Please check any and all of the features available at the above listed Clubs: Residential/Group Home Emergency Shelters Mentor Program Pregnant Teen Center Transitional Living Shelters Other Are volunteers/mentors allowed to take club participants off-site? If yes, please describe protocols that are currently in place: COMMERCIAL COOKING List locations where commecial cooking is performed, or attach schedule: Address Is there a suppression system? Is there an automatic fuel shut off? Is cleaning of hood and duct contracted out? AUTOMOBILE Are volunteers allowed to drive Club vehicles? volunteers at all locations who regularly use their own autos to transport social service clients in connection with your programs: How frequently are MVRs checked on all drivers? Are children transported to and from off-site locations? If yes: How many vehicles are used? Who drives the vehicles (e.g. Club staff, contractors, etc.)? Page 6
AUTOMOBILE CONTINUED Are certificates of Insurance obtained for volunteers that drive their automobile for Club business? If Yes, what automobile limits are they required to carry? Does your Club ever outsource transportation to local companies? If Yes, what is the annual cost of hire? Please attach a copy of Certificates of Insurance obtained from the transportation company. COMPLETE AND SIGN Please print the electronically completed portion of this form (if applicable) & complete the following: Print Name: Signature: Title: Date: Page 7