Sponsor: ___________________________________________
Date of Trip: ________________________________________
Name of Driver:_______________________________________
Boulder Valley School District RE-2J
Student Transportation in Private Vehicles
Boulder Valley School District does NOT insure school related trips in private vehicles. The
district does not carry insurance on private vehicles driven by parents or volunteers. It is
Board Policy (EEAE/EEAG) and therefore required that the owner carry a minimum of thefollowing:
$100,000/$300,000 liability,
$50,000 property damage and
Uninsured Motorist$25,000/$50,000.
Board Policy EEAE/EEAG is on the back of this form. Please read it carefully beforecompleting the remainder of the form. Thank you.
Model/Year of Car:
Insured by:
Liability Coverage ($):
Property Damage Coverage ($):
Seat Belts: Yes for # Passengers No (unable to drive)
Maximum number of passengers: ALL PASSENGERS MUST WEAR SEATBELTS*
Valid Driver’s License Number:
Current proof of insurance coverage must be submitted with this form. Driver unable
to drive without proof of coverage.
As a driver for field trips during the school year ___ to ___, I understand that the district carries no insurance for private vehicles or students or drivers.
I am personallyresponsible. I also certify that I am at least 21 years of age.
Driver Signature: ____________________________________
Sponsor Signature: _____________________________________
Principal Approval/Signature: _____________________________
Date: ________________________________
Revised 8/04 11