LOS GATOS-SARATOGA HIGH SCHOOL DISTRICT
FIELD AND ACTIVITY TRIP PRIVATE CAR TRAVEL CHECK
I, _____________________________________
will be using the automobile described below to
(Name of Driver
transport students to ___________________________________
for ______________________
(Activity/Sport)
(Event/Season)
VEHICLE MAKE: ____________________________
YEAR AND MODEL: __________________________
VEHICLE LICENSE NUMBER: _________________ |
Valid
Driver’s License:
_________________________________ __________________
(Driver’s License Number)
(Expiration Date)
|
Check Box if Requirement Satisfied.
Proof
of Insurance (Must be in Automobile)
____________________________ ___________________ ____________________
(Insurance Company)
(Policy
Number)
(Expiration Date)
MINIMUM
COVERAGE: $5,000 Medical
$300,000 per occurrence Bodily injury/property
damage insurance.
Private coverage will be primary. |
Safety Check (self check)
The following have been inspected and are in safe
working condition:
Tires _____ Brakes _____ Lights
_____ Turn Signals _____ |
Seat Belts
A seat belt is available for each passenger. Each passenger will be required to wear a seat belt. |
Driving Record
I certify that I have not had a moving violation
or had my license suspended during the last three years. |
Date ________________________ Signed ____________________________________
(Driver of Vehicle)
I am the registered
owner of the vehicle described on this form and I authorize the driver, whose name appears above to use this vehicle to transport
him/herself and students. I certify that the information provided above is correct. I understand that my insurance, as described above provides primary coverage.
Date ________________________ Signed ___________________________________
(Owner of Vehicle)
