Form Mis 5186 - Agreement Governing The Use Of Private Autos For School Business printable pdf download

MIS 5186

REV 6/15

OKALOOSA COUNTY SCHOOL DISTRICT

OFFICE OF RISK MANAGEMENT AND INSURANCE

AGREEMENT GOVERNING THE USE OF PRIVATE AUTOS FOR SCHOOL BUSINESS

Complete the following for each privately owned vehicle to be used for transporting students to and from related activities.

TO BE COMPLETED BY VEHICLE OWNER

Model of Vehicle ________________________________________

Name of Owner (Print) __________________________________

Year of Vehicle __________________________________________

Name of Driver (Print) ___________________________________

Make of Vehicle _________________________________________

Vehicle Tag Number _____________________________________

I certify that the above described vehicle, which is to be used only for the approved transportation purposes set forth below, is covered by

bodily injury liability insurance equaling or exceeding $200,000 per person / $300,000 per occurrence and personal injury protection (“No-

Fault”) coverage equaling or exceeding $10,000 per person and that I will maintain the required insurance coverages at all times while my

vehicle is used for student transportation. In the event of an accident while the vehicle is operated on school business, I will report all

details of the accident to the school principal or his/her designee as soon as possible but in no event any later than 24 hours after the

accident and understand that the financial loss for damage to my vehicle shall NOT be reimbursable by the District or the District Self-

Insurance Fund.

This coverage is with _________________________________________________ Insurance Company and expires on ________________.

Month/Day/Year

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.) Yes ____ No ____ NOTE: If No, the vehicle is NOT to be used for transporting students.

Signature of Owner ___________________________________________________________________________ Date ________________

Address ______________________________________________________ City ____________________________ State ______________

Zip Code ________________ Home Phone ( _______ ) _________________ Cell Phone ( _______ ) _________________

TO BE COMPLETED BY VEHICLE DRIVER

Driver’s License: State _________________________ Number ____________________________________________________________

I understand that I am authorized to use only the aforementioned vehicle for transportation of students, and that I am only authorized to

transport students for the purpose of _________________________________ (e.g. field trip, illness, recreational outing, interscholastic

competition, etc.) to the following location and back ___________________________________________________ and that I am not to

deviate from the authorized transportation destinations. This authorization to transport students must be granted by the school principal

or his/her designee and is required for each event or activity for which I provide transportation. I understand that I cannot provide

transportation to pupils until my driving record has been checked by the school district and it is confirmed that I have not had more than

three driving infractions in the past three years or a DUI in the past ten years.

I understand that all passengers will be seated in designated seating positions and shall be required to use the occupant crash protection

system provided by the vehicle manufacturer.

Signature of Driver ___________________________________________________________________________ Date ________________

Address ______________________________________________________ City ____________________________ State ______________

Zip Code ________________ Home Phone ( _______ ) _________________ Cell Phone ( _______ ) _________________

TO BE COMPLETED BY THE SCHOOL PRINCIPAL OR DESIGNEE

School ________________________________________Teacher / Sponsor __________________________________________________

The above driver and vehicle is approved to transport students on ________________ (Date).

Signature of Principal or Designee_______________________________________________________________ Date ________________

Form Mis 5186 - Agreement Governing The Use Of Private Autos For School Business

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