School Driver Registration Form

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E 3541.1
TRANSPORTATION FOR SCHOOL-RELATED TRIPS
School Driver Registration Form
This form must be completed annually, or if your insurance policy changes.
School: ________________________________________
School Year: ____________________
DRIVER INFORMATION
Driver (circle one):
Employee
Parent/Guardian
Volunteer
Name:_______________________________________ Date of Birth: ________________________
Address: _________________________________________________________________________
Telephone: (___)__________________________ Cell Phone : (___)_________________________
Driver’s License No.:______________________________Expiration Date: _____________________
VEHICLE INFORMATION
Name of Owner: ___________________________________________________________________
Address: _________________________________________________________________________
Make and Model: ________________________ Year: _______ License Plate No.: ______________
Registration Expiration Date: ____________________ Seating Capacity: _____________________
(Passenger Seats with Belts)
Has driver ever been cited for any moving traffic violations in the past year?
Yes: ______ No: ______ If yes, please attach an explanation. Indicate number of violations and
circumstances.
INSURANCE INFORMATION
Insurance Company: ________________________________ Telephone No.: (___)______________
Policy No.: ____________________________________Expiration Date: ______________________
Liability Limits of Policy: _____________________________________________________________
DRIVER STATEMENT
I certify that I have not been convicted of reckless driving or driving under the influence of drugs or
alcohol within the past five years and that the information given above is true and correct. I
understand that if an accident occurs, my insurance coverage, a minimum of $100,000 per person,
$300,000 per occurrence, and $5,000 property damage per accident, shall bear primary responsibility
for any losses or claims for damages. As proof of insurance, a copy of your Auto Insurance
Declaration Page showing limits of liability is REQUIRED.
I certify that I have received and will abide by the driver instructions provided by the district.
____________________________________________________
_____________________
Signature of Driver
Date
_______________________________________
__________
___________ ______________
Signature of Principal
Approved
Not Approved
Date
District Master Forms/Transportation for School Trips 08/2011

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