CHICAGO PARK SCHOOL DRIVER CERTIFICATION FORM



CHICAGO PARK DISTRICT DRIVER CERTIFICATION FORM

Student: Grade:

DRIVER (must be at least 21 years of age) (circle one) Parent Employee Volunteer

Name:

Address:

No. & Street City Zip

Home Phone #: Work #: Cell #:

Drivers License #: Expiration Date:

VEHICLE

Name of Registered Owner:

Address:

Year : Make & Model: Color:

License Plate #: Registration Expires: No. Seat Belts :

(Other than driver)

Passenger air bag(s)? ________

INSURANCE INFORMATION

Insurance Company: Policy #: Expiration Date:

Liability Limits of Policy

(per person) (per accident) (property damage)

|According to Board Policy 3541.1, drivers are required to possess a valid California driver's license or a valid driver’s license from his/her state of |

|residence if he/she is a non-resident on active military duty in California. A driver shall be required to have a good driving record and at least the |

|District required minimum liability insurance per occurrence, which is $100,000 per person, $300,000 per accident/bodily injury and $50,000 property damage. |

|The driver also ensures that manufacturer’s recommendations for his/her vehicle are followed regarding the seating of children in seats equipped with |

|airbags. All drivers shall wear seat belts in accordance with the law. In addition, drivers shall ensure that a child who is under age 8, be secured in a car|

|or booster, unless exempted by law and, all other passengers wear seat belts. Whenever said vehicle is used for student transportation, the driver will |

|maintain it in a safe operating condition; drive in a safe and courteous manner; and, follow prescribed routes and timelines to the best of his/her ability. |

Name of Agent: Phone #:

I certify that the information given above is true and correct. I understand that if an accident occurs, as the registered owner, my insurance coverage and I shall bear primary responsibility for any losses or claims for damages. I have read and understand the information provided in the attached Driver Instruction Form and will keep this form in my car when transporting students. I agree to provide a copy of my driver’s license, insurance policy showing my liability limits, and my DMV driving record. You can obtain your driving record at

Signature: Date:

PLEASE RETURN COMPLETED FORM WITH COPIES OF YOUR DMV DRIVING RECORD, INSURANCE POLICY SHOWING LIABILITY LIMITS AND YOUR DRIVER’S LICENSE.

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