UKIAH UNIFIED SCHOOL DISTRICT
PRIVATE VEHICLE USE FORM
As a driver of a vehicle, I understand that I must have:
1. A valid California driver’s license. Drivers with moving infractions within one year’s time of the court declaration date could be denied authorization to transport students.
2. Required liability insurance on my car (specified in School Board Policy below):
2.1. - Each parent utilizing a private vehicle must show evidence of insurance carrying liability of a minimum of $100,000/$300,000 split limit or combined limit of $300,000. Evidence of insurance requires a photocopy of the coverage. (AR 402.6.3.b)
2.2. - Each parent utilizing a private vehicle must be informed that in the event of an accident, the parent’s insurance would be responsible for liability up to the limit of $100,000/$300,000 split limit or combined limit of $300,000. This District’s insurance will be liable for any amount in excess of the $100,000/$300,000 carried by the parent (not to exceed $1,000,000 limit of the District’s liability coverage). (AR 402.6.3.c)
2.3. - Permission and medical treatment forms must be carried in private vehicles for student passengers.
3. A vehicle in safe operating condition:
3.1. - Brakes are good; windshield wipers, head lights, tail lights, brake lights work; tires have adequate tread; operational seat belts are available and are worn by all passengers. (BP 608)
3.2. - Five passengers plus driver – transportation limit for 6 passenger sedan. Eight passengers plus driver – station wagon/SUV transportation limit. Beyond the above capacity requires a special driver’s license (vans for 10-15 persons).
3.3. - Current Driver’s License Number:_____________________________________________
3.4. - Driver’s Vehicle License Number: _____________________________________________
3.5. - Vehicle Model and Year: ____________________________________________________
I understand that it is my responsibility to provide a copy of my DMV printout, a copy of insurance as specified in 2.1 above and this form completed and signed prior to the event.
I also understand that drivers shall not use tobacco products per Board Policy AR 402.6.3.d while transporting students.
I hereby acknowledge that as a driver providing my own vehicle, I have read and understand the information provided herein. My signature below hereby affirms that I fully accept and agree to the terms and obligations as stipulated.
PRINT NAME: _______________________________________________________________________________
Driver of Car
DRIVER’S SIGNATURE:_________________________________________________
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___________________
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Date
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SCHOOL NAME: _____________________________________________________________________________
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FOR DISTRICT USE: APPROVED ☐
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/ ☐ DENIED
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REASON FOR DENIAL:_________________________________________________________________________________
___________________________________________________________________________________________________
PRINCIPAL’S SIGNATURE: ______________________________________________
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Date
DISTRIBUTION: Signed original on file at School Site ~ Signed copy to Driver
~ Signed copy to Transportation
Z:\Personnel\Common\Forms\Private Vehicle Use Form.doc