Transportation Release Form - Belton School District printable pdf download

TRANSPORTATION RELEASE FORM

FOR CO-CURRICULAR AND EXTRA CURRICULAR PROGRAMS

Notice to Parents and Guardians: For some extra-curricular and co-curricular activities private transportation

may be used. In such cases, parents are responsible for ensuring their student is following safety guidelines.

Please communicate with your student in order to know with whom he or she may be riding.

1. Student riding with other licensed drivers (other than authorized district personnel):

I give my consent for ____________________________________ (student name) to ride with other

licensed drivers, including other students, to and/or from school-related activities or practices.

YES ____________ NO ____________

2. Student providing his/her own transportation:

I give my consent for ____________________________________ (student name) to drive an

automobile owned or leased by him/her or me to and/or from school-related activities or practices.

YES ____________ NO ____________

3. Student transporting other students:

I give my consent for ____________________________________ (student name) to transport other

students to and/or from school-related activities or practices.

YES ____________ NO ____________

If you answered “YES” to either number 2 or 3 above, please complete the next section:

____________________________________________ (Student name) holds a valid driver’s license and is in

compliance with Missouri state law.

____________________________________________ (Student name) is insured by an automobile liability

insurance policy, which is in compliance with the requirements of the Missouri law.

Student’s Driver’s License Number ____________________________________ State ___________________

Insurance Company _______________________________________ Policy Number ____________________

*By my signature below, I understand and agree that the District assumes no liability, and I hold the District

harmless, for my transit/the transit of my child, or for incidents related to my transit/the transit of my child,

while traveling in a private vehicle. I further agree that I/my child is not in the care, custody, and/or control

of the District while traveling to or from co-curricular or extra-curricular activities in a private vehicle.

***SIGNATURES REQUIRED BELOW***

Signature of Parent or Guardian ______________________________________________ Date ___________

Signature of Student _______________________________________________________ Date ___________

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Transportation Release Form - Belton School District