St. Anselm School - Field Trip Permission Form

Students' Name(s):

First NameLast Name
Email*
example@example.com
Grade
Thank you for volunteering your services to assist in transporting children on school-sponsored activities. Prior to using a private automobile for an educational field trip, the driver must complete, sign, and have this form on file in the school office. This form must be completed at least once each school year. Whenever the information changes (i.e. change of expiration date) the form must be updated.
1. DRIVER INFORMATION
Driver (circle one):

Parent/GuardianEmployee
Mother's Name:

First NameLast Name
Date of Birth:

MonthDayYear
Date
Father's Name (if he will be driving):

First NameLast Name
Date of Birth:

MonthDayYear
Date
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Mother's Driver's License #
Expiration Date:

MonthDayYear
Date
te: Father's Driver's License #
Expiration Date:

MonthDayYear
Date
Telephone Number
Please enter a valid phone number.
Mobile Number
Please enter a valid phone number.
Phone Number
Please enter a valid phone number.
2. VEHICLE INFORMATION
Name of owner:

First NameLast Name
Address:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Make of vehicle:
Color:
Year:
License Plate#:
Registration Expiration:

MonthDayYear
Date
Seating Capacity (with seat belts, excluding front passenger seat if there is a front passenger air bag)
3. INSURANCE INFORMATION
Insurance Company
Telephone Number:
Please enter a valid phone number.
Policy
Expiration Date:

MonthDayYear
Date
REQUIRED LIMITS: $100,000/$300,000 BODILY INJURY $25,000 PROPERTY DAMACE
Insurance policy limits:
Bodily Injury:
Property Damage:
EDUCATIONAL FIELD TRIP DRIVER FORM
- The vehicle capacity is one passenger per seat belt. All passengers shall use their seat belts. No child may sit in the front seat with an air bag. Use of child car seats shall be in accordance with the law.
- The vehicle is in a safe operating condition based on inspection by me, as to lights, horn, turn signals, brakes, tires, and suspension.
- I have no physical limitations that would adversely affect my ability to drive safely.
- My cell phone will be used only in case of an emergency while on school field trips.
- I am not taking any medication that would adversely affect my ability to drive safely.
- I have no prior convictions for driving under the influence, nor will I consume any alcoholic beverages or other drugs while on a school-sponsored trip or excursion.
- I will drive directly to and from event without any unscheduled stops.
Please Note: If you drive your personal automobile while on a school field trip and you are involved in an accident, by law your liability insurance policy is used first, St. Anselm's school liability policy would be used only after your policy limits have been exceeded. The District does not cover, nor is it responsible for, comprehensive and collision coverage to your vehicle.
Signature of Driver

Clear
Date

MonthDayYear
Principal's Approval:

Clear
Date

MonthDayYear
Should be Empty:

1. DRIVER INFORMATION

2. VEHICLE INFORMATION

3. INSURANCE INFORMATION

REQUIRED LIMITS: $100,000/$300,000 BODILY INJURY $25,000 PROPERTY DAMACE

EDUCATIONAL FIELD TRIP DRIVER FORM