LOS GATOS UNION SCHOOL DISTRICT
SCHOOL DRIVER REGISTRATION FORM
(to be completed once a year or when a change to the information provided occurs)
Driver: (check one) Employee Parent/Guardian Volunteer
Name: ______Teacher: ______
Student’s Name: ______Telephone #: ______
Address: ______Cell/Pager #: ______
______Work Phone #: ______
Driver’s License #: ______Expiration Date: ______
VEHICLE INFORMATION
Name of Owner: ______Year: ______
Address: ______Make: ______
______License Plate #: ______
Registration Expires: ______Passenger Capacity: ______
INSURANCE INFORMATION
Insurance Company: ______Policy #: ______
Telephone #: ______Expiration Date: ______
Liability Limits of Policy: ______($100,000/one person, $300,000/two persons for each occurrence)
ALL DRIVERS MUST BE 21 YEARS OF AGE OR OLDER
I certify the above information is correct and the insurance coverage is in force. I understand I must have liability insurance coverage in force and agree to advise the District, in writing of any changes in the above information. I further certify that the above vehicle is mechanically safe and that I am physically and mentally able to drive students on school sponsored trips.
Your vehicle cannot be overcrowded. There can be no more passengers than there are available seat belts. All passengers must be in seat belts at all times. Child passengers must be properly secured in a rear seat in a child passenger restraint system meeting applicable federal motor vehicle safety standards, unless the child is one of the following: (1) six years of age or older (2) sixty pounds or more. Students may not be transported in open pickups, or in vehicles where there are no seat belts provided. Each driver must proceed directly to and from the study trip destination; there should be no unauthorized stops. The use of fifteen or twelve passenger vans is prohibited.
When you drive your personal automobile while on District business, including study trips, and you are involved in an accident, by law your insurance policy is used first. The District insurance policy would be used only if 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 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 shall bear primary responsibility for any losses or claims for damages.
I fully understand as a driver I am to abide by the rules and regulations governing conduct during the trip. I do hereby waive all claims and hold harmless the individual sponsor, the Los Gatos Union School District, and the State of California for any injury, accident, illness, death or any loss or damage to personal property occurring during or by reason of this excursion/study trip or event.
______
Driver’s Signature Date
8/6/09 drh