ST. ANSELM SCHOOL EDUCATIONAL FIELD TRIP DRIVER FORM ONE FORM PER VEHICLE PLEASE READ AND SIGN THE BACK OF THIS FORM. *****REMEMBER TO ATTACH YOUR INSURANCE DECLARATION PAGE***** Students’ Name(s): _____________________________ _____

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Grade

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Thank you for volunteering your services to assist in transporting children on school-sponsored activities. Prior to using a private automobile for an educational field trip, the driver must complete, sign, and have this form on file in the school office. This form must be completed at least once each school year. Whenever the information changes (i.e. change of expiration date) the form must be updated. 1. DRIVER INFORMATION Driver (circle one):

Parent/Guardian

Employee

Mother’s Name:________________________________________ Date of Birth: ___________ Father’s Name (if he will be driving): ______________________ Date of Birth: ___________ Address: _____________________________________________________________________ Mother’s Driver’s License #: ________________________Expiration Date: _______________ Father’s Driver’s License #: ________________________Expiration Date: _______________ Telephone #: _________________ M. Cell #: ____________ F. Cell #: ________________ 2. VEHICLE INFORMATION Name of owner: ________________________________________________________________ Address: _____________________________________________________________________ Make of vehicle: ______________________________ Color: ___________ Year: ________ License Plate #: _______________________________ Registration Expiration: ___________ Seating Capacity: ____________ (with seat belts, excluding front passenger seat if there is a front passenger air bag) 3. INSURANCE INFORMATION Insurance Company: __________________________ Telephone #: _____________________ Policy #: _____________________________Expiration Date: __________________________ REQUIRED LIMITS: $100,000/$300,000 BODILY INJURY $25,000 PROPERTY DAMACE Insurance policy limits: Bodily Injury: ____________________________ Property Damage: ____________________

EDUCATIONAL FIELD TRIP DRIVER FORM •

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The vehicle capacity is one passenger per seat belt. All passengers shall use their seat belts. No child may sit in the front seat with an air bag. Use of child car seats shall be in accordance with the law. The vehicle is in a safe operating condition based on inspection by me, as to lights, horn, turn signals, brakes, tires, and suspension. I have no physical limitations that would adversely affect my ability to drive safely. My cell phone will be used only in case of an emergency while on school field trips. I am not taking any medication that would adversely affect my ability to drive safely. I have no prior convictions for driving under the influence, nor will I consume any alcoholic beverages or other drugs while on a school-sponsored trip or excursion. I will drive directly to and from event without any unscheduled stops.

Please Note: If you drive your personal automobile while on a school field trip and you are involved in an accident, by law your liability insurance policy is used first, St. Anselm’s school liability policy would be used only after your policy limits have been exceeded. The District does not cover, nor is it responsible for, comprehensive and collision coverage to your vehicle. I CERTIFY THE ABOVE INFORMATION IS CORRECT AND THAT THE INSURANCE COVERAGE IS CURRENT. I AGREE TO ADVISE ST. ANSELM SCHOOL IN WRITING OF ANY CHANGES IN THE ABOVE INFORMATION. I UNDERSTAND THAT MY INSURANCE IS PRIMARY IN CASE OF AN ACCIDENT AND THAT ST. ANSELM SCHOOL ACCEPTS NO RESPONSIBILITY FOR DAMAGE OR LOSS TO MY VEHICLE. I ACCEPT THE RESPONSIBILITY OF MAKING SURE THAT ALL PASSENGERS WILL WEAR SEAT BELTS AND THAT I WILL NOT PUT A CHILD IN THE FRONT SEAT IF THERE IS AN AIRBAG. Signature of Driver: ______________________________________ Date: ________________ Signature of Driver: ______________________________________ Date: ________________ Principal’s Approval: _____________________________________ Date: ________________ This form expires June 30, 2017 and must be renewed at the beginning of each new school year.