PLEASE include the following with this form:

1. Copy of driver’s license
2. Insurance Declaration Form ($300k bodily injury, $100k uninsured motorist, $50k property damage)

Please email these 3 items to: gabriel.kittle-cervine@pcscharter.org

• I certify that the above information is correct and that the insurance coverage is in force.
• I further certify that the above vehicle is mechanically safe.
• I also certify that I am over the age of 25.
• I acknowledge that the purpose of this form is to establish that I understand and agree that I am primarily liable for
  any and all claims to and from field trips, community service events, club and athletic events and any other
  school‐sponsored and supervised events or excursions.
• I acknowledge that it is my responsibility to notify PCS, in writing, of any changes in any of the above information
• I understand that California law requires that each passenger be provided and wear a seat belt at all times.
• In no event will I transport more than 9 passengers plus myself in the vehicle at any time.
• Children under the age of 13 years must be seated in the back seats only.
• California law requires that drivers understand and agree that they waive all claims against PCS and the State of
  California for injury, accident, illness, or death occurring during or by any reason of the field trip, excursion or event.
• I understand and agree that in the event of an accident while I am driving PCS students, my insurance policy is used
  first.
• I will NOT drive students until I have shown event coordinator a copy of this approved form that shows current drivers
  license and insurance.