VOLUNTEER DRIVER INFORMATION SHEET

I. Driver:

Name_____________________________ Date of Birth

Address___________________________ Phone #

City_______________________________ Zip Code

Driver License #

II. Vehicle that will be used:

Name of Owner______________________ Year & Make

Owner Address______________________ Model

______________________________License Plate

Registration Expires Number of Seats with Belts

If more than one vehicle is to be used, requested information must be provided for each vehicle.

III. Insurance Information:

When using a privately owned vehicle, the insurance coverage is the limit of the insurance policy covering that specific vehicle.

Insurance Company

Policy Number

Expiration Date

Liability Limits of Policy*

*Please note: As of August, 2003: The minimal, acceptable liability for privately owned vehicles is $250,000/$500,000. It is recommended that parents consider expanding coverage to $500,000.00 CSL (Combined Single Limit). The additional coverage is considered appropriate protection and, generally, inexpensive to purchase.

IV. Certification:

I hereby certify that the information given on this form is true and correct to the best of my knowledge. I understand that as a volunteer driver, I must be 21 years of age or older, hold a valid driver's license, and have the required insurance coverage in effect on any vehicle used to transport students.

__________________________________________

(Signature)

__________________________________________

(Date)

It is recommended that a photocopy of the driver’s valid driver’s license and auto insurance policy be attached to this form.

FORM 6153.88 VOLUNTEER (revised 8/2003)