PARENTAL CONSENT FOR TRANSPORTATION BY PRIVATE VEHICLE

I have reviewed the following information and consent to my child being transported by private vehicle for this purpose.

Purpose of the trip (s) ____________________________________________________

Date (s) of the trip (s) _____________________________________________________

Time of Departure _________________ Time of return to school _________________

Owner of the vehicle _____________________________________________________

Driver of the vehicle _____________________________________________________

Description of the vehicle ________________________________________________

Amount of liability insurance on the vehicle $__________________________________

The school verifies that the driver has a valid operator's license, the vehicle is in proper operation condition, and a safety belt will be available for you child.

REQUEST FOR TRANSPORT BY PRIVATE VEHICLE

Requesting Staff Member _______________________________________________________

Purpose of Trip _______________________________________________________________

Date (s) of the Trip (s) ____________________________________

Time (s) of Departure ________________________  Time (s) of Return ___________________

Owner of the Vehicle _________________________________________________________

Driver of the Vehicle __________________________________________________________

Amount of Liability Insurance ____________________________________________________

Name of Insurance Company _____________________________________________________

I have verified the following:

[]     There is a safety belt for each passenger.

[]     The driver has a valid operator's license in this State.

[]     Each student's parent has provided written consent to the trip.

[]     The vehicle is in proper operation condition.

[]     No hazardous road conditions on the itinerary are forecast.

[]     Proper transportation has been arranged for each student upon return to the school.

[]     No other person other than the driver listed above will be driving the vehicle during the trip.

***********************************************************************************