EmailMe Form - MSF Driver Authorization Form

Driver's Name *

First Last

Driver's Date of Birth *

MM / DD / YYYY

Driver's SSN

Driver's License Issuing State and Driver's License Number *

Driver's License Expiration Date *

MM / DD / YYYY

Driver's Home Address *

Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country

Driver's Phone Number *

### - ### - ####

Vehicle to be Used

Name of Vehicle Owner *

First Last

Address of Vehicle Owner *

Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country

Vehicle Make *

Vehicle Model *

Vehicle Model Year *

Vehicle License Plate *

Vehicle License Plate Expiration Date *

MM / DD / YYYY

Insurance Information

When using a privately owned vehicle, the insurance coverage is the limit of the insurance policy covering the specific vehicle.

Insurance Company *

Policy Number *

Policy Expiration Date *

MM / DD / YYYY

Liability Limits *

Note: The minimal acceptable liability limit for privately owned vehicles is $100,000/$300,000.

Driving History

Have you had citations or convictions of any of the following in the last three years?

Driving under the influence of alcohol or drugs? *

Yes

No

Hit and run? *

Yes

No

Failure to report an accident? *

Yes

No

Negligent homicide arising out of the use of a vehicle? *

Yes

No

Using a motor vehicle for the commission of a felony? *

Yes

No

Permitting an unlicensed person to drive? *

Yes

No

Reckless driving? *

Yes

No

Speed contest? *

Yes

No

Any combination of accidents or moving violations that total three or more? *

Yes

No

In order to provide for the safety of our students, we cannot use your services as a driver if you do not have a current, valid driver's license and insurance on your vehicle. If you answered yes to any of the questions concerning driving citations or convictions, we must also disqualify you as a volunteer driver.

Driving Requirements and Certifications

Please read the following requirements and complete the certification below.
1. Children must be attended by an adult while in the vehicle.
2. A second adult must be in the vehicle supervising when 8 or more children under 5 years of age are being transported.
3. A child under 4 years of age or under 40 lbs must be secured in a federally approved child safety seat that is properly installed and used.
4. According to state law effective 7/1/04, all children ages 4-8 and less than 5 feet tall must ride in the back seat in a booster seat.
5. Storage of firearms is prohibited in vehicles used to transport children.
6. Upon arrival at a field trip destination, volunteer drivers must wait for a member of MSF's staff to arrive before allowing children to leave the vehicle.

Electronic Signature *

First Last

Please enter your (driver's) name to sign electronically and indicate that you have read the requirements on this form, that all information provided is true and correct to the best of your knowledge. I understand that as a volunteer driver, I must be 21 years of age or older, possess a valid driver's license, have the proper and current license and vehicle registration, and have the required insurance coverage in effect on any vehicle used to transport students. I agree to hold Montessori School of Franklin harmless from any liability arising out of or in connection with transportation during field trips.

Date *

MM / DD / YYYY