Private Vehicle/Insurance Information

Complete the following for each privately owned vehicle used to transport scholars to and from school-related activities.

TO BE COMPLETED BY VEHICLE OWNER

Name of Owner(Required)

Model of Vehicle(Required)

Name of Driver(Required)

Year of Vehicle(Required)

Make of Vehicle(Required)

Vehicle Tag Number(Required)

This coverage is with(Required)

Insurance Co. and expires on(Required)

MM/DD/YYYY

This vehicle complies with the Federal Motor Vehicle Safety Standards. (Verification of compliance is normally reflected by a sticker located in the door well of the driver's door.)(Required)

NOTE: If No, the vehicle is NOT to be used to transporting scholars.

Yes

Signature of Owner(Required)

Date(Required)

Address(Required)

Street Address City State / Province / Region ZIP / Postal Code

Phone(Required)

TO BE COMPLETED BY VEHICLE DRIVER

Driver's Licence State:(Required)

Driver's License Number:(Required)

I understand that I am authorized to only use the aforementioned vehicle for transportation of scholars, and that I am only authorized to transport scholars for the purpose of (field trip/illness/recreational outing/interscholastic competition) to the following location and back and that I am not to deviate from the authorized transportation destinations.(Required)

Enter purpose and location

Signature of Driver(Required)

Date(Required)

Address(Required)

Street Address City State / Province / Region ZIP / Postal Code

Phone(Required)