2019 - 2020 DCSD AUTHORIZATION TO USE PRIVATELY OWNED VEHICLE ON SCHOOL DISTRICT BUSINESS

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You agree to check-in at the front office and provide a valid Colorado Driver's License or ID prior to performing any/all volunteer commitments.

Douglas County School District - Risk Management
Phone: 303-387-0030 Fax: 303-387-0112

This form should be completed and proof of insurance coverage submitted to the school so it can be received by Risk Management a minimum of two weeks prior to the event to ensure adequate time for the approval process.

I. Driver Information

Please Complete ALL Boxes

Driver's First Name *

Driver's Last Name *

Driver's Address *

Street, City, State, Zip Code

Driver's Phone Number *

xxx-xxx-xxxx

School Name *

Renaissance Expeditionary Magnet School

Required

Purpose *

School trips such as; Voyages, Expedition Field Work, Service Learning, etc.

Required

Driving Date(s) *

2019-2020 School Year

Required

Relationship with Student / District *

Vehicle Description *

Make and Model

Number of Passengers *

How many passengers can your vehicle carry in the back seat(s)?

II. Certification

In accordance with District Policy, approval is requested to use a privately owned automobile on official school District business.

1. I certify that my privately owned vehicle, while used for District business, will always be:
a. Covered by liability insurance for the minimum amount prescribed by the District:
$300,000 single limit or $100,000/$300,000/$25,000 automobile liability insurance with Uninsured/Underinsured coverage.
b. Equipped with one fully functional seat belt for every passenger.
c. To the best of my knowledge, in safe mechanical condition and adequate for passenger transportation and/or work performed.

2. I further certify that while using a privately owned vehicle on official District business, all motor vehicle laws will be obeyed, including all passengers’ use of seat belts and use of booster seats for any child less than 40 pounds or under 6 years of age (per Colorado State Law).

Note: Any traffic accidents, no matter how minor, will be reported immediately to Risk Management at 303-387-0035.

3. I further certify that I have not been convicted of Driving Under the Influence, Driving While Impaired or Reckless Driving in the past five years.

4. I further certify that I am at least 21 years old, and that I possess a valid Colorado Driver’s license as follows:

Driver's License Number *

Driver's License Expiration Date *

YYYY

Driver's Date of Birth *

YYYY

III. Proof of Insurance

A copy of your current policy DECLARATIONS page stating coverage limits, policy effective dates, and covered vehicle information MUST be provided to the school.

Insurance Company *

Policy Number *

Policy Expiration Date *

YYYY

Electronic Signature

By entering my name below, I understand that I am providing an electronic signature which will serve as authorization and verification of the accuracy and completeness of the information I have provided.

Full Name *

Date Signed *

mm/dd/yyyy

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