Parish __________________________________School _________________________________

1. Driver:

Name _________________________________ Date of Birth ________________________

Address _______________________________ Soc. Sec. No. ________________________

______________________________________ Telephone __________________________

Driver’s License No. _____________________ Date of Expiration ___________________

2. Vehicle that will be used:

Name of Owner _________________________ Model of Vehicle _____________________

Address of Owner _______________________ Make of Vehicle ______________________

______________________________________ Year of Vehicle _______________________

License Plate No. _______________________ Date of Expiration _____________________

Registration Expiration Date __________________________________

3. Insurance Information:

Insurance Company _______________________________________________________________

Policy No. _______________________________________________________________________

Date of Policy Expiration ___________________________________________________________

Liability Limits of Policy** _________________________________________________________

** Please note: The minimal acceptable liability limit for privately-owned vehicles is $100,000/$300,000.

4. Certification:

I certify that the information given on this form is true and correct to the best of my 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 coverage in effect on any vehicle used to transport the children.

_________________________________________ ____________________

Signature                                                                                 Date