Volunteer or Employee Vehicle Usage Form

Great Falls School District
1100 4th Street – Great Falls, MT 59405 – (406) 268-6051
Please read each item below carefully. On the line to the left of each item put your initials indicating
that you have read, understand and will comply with the requirements indicated.
Return this completed form to Brian Patrick, Director of Business Operations, for review and approval.
Volunteer/employee drivers using their vehicles to transport students on field trips or other school-sponsored and districtapproved field/activity trips must comply with the following requirements:
_____ 1. I certify that I have a valid Montana drivers license and there are not restrictions preventing me from
transporting students in my vehicle.
_____ 2. I am 21 years of age, or older, which is the minimum age to transport students.
_____ 3. I certify that I have not received a DWI (Driving While Intoxicated/Impaired), DUI (Driving Under the Influence),
OWI (Operating While Intoxicated), OUI (Operating Under the Influence, refusing substance tests, reckless driving,
manslaughter, hit and run, eluding a police officer, any felony, drag racing, license suspension or driving while license
suspended in the last 36 months.
_____ 4. I consent to the school district checking my Motor Vehicle Record (MVR) with the Department of Motor Vehicles
_____ 5. I certify the vehicle is equipped with seat belts for all occupants and I will comply with the law requiring each
passenger, including the driver, to use a seat belt. There is to be no sharing of seat belts.
_____ 6. I will only carry the number of passengers for which the vehicle is designed, not to exceed more than a total of
six passengers, including the driver. I understand that trucks or pickups may carry only as many as can safely sit in the
passenger compartment and the no passengers will ride in the back (bed).
_____ 7. Emergency information for each occupant (both students and adults) will be maintained in the
_____ 8. The following minimum insurance coverage amounts if private vehicles are used: $300,000 bodily injury liability
and property damage combined, $5,000 medical and $300,000 under and uninsured motorist.
_____ 9. I certify the vehicle is regularly maintained and kept in good mechanical condition. I understand it is
recommended that a first aid kit and fire extinguisher be carried in the vehicle.
_____ 10. I understand that the insurance coverage on my personal vehicle is primary insurance coverage the Great
Falls School District’s liability coverage will be excess to my coverage. I also understand that the School District does not
carry any physical damage coverage for my vehicle and this is my responsibility.
_____ 11. I Understand I will need to complete a New Volunteer or Employee Vehicle Usage Form upon expirations of
my driver’s vehicle insurance policy.
_____ 12. I will report accidents/injuries to the Director of Business Operations at (406) 268-6051 as soon as possible.
Driver and Insurance Information
Date of Birth:
Home #:
Work #:
Cell Phone #:
Drivers Lic. #:
(Copy of Drivers License) Class:
Expiration Date:
Moving violations received, if any, in the past 3 years? #
Explain *
Number of accidents, if any, in the past 3 years? #
(*Use additional sheet, if necessary, for explanation and attach it to this form.)
Insurance Company:
Telephone #:
Policy #:
(Copy of Insurance Card) Expiration Date:
Volunteer/Employee’s Signature:
School/site Administrator’s Signature:
Revised 7-11-13