School Info

	School Name*field type drop-down	School Year*field type drop-down
row 1	School Name*field type drop-down	School Year*field type drop-down

Volunteer Info

	Last Name*field type single line	First Name*field type single line	Middle Namefield type single line	Email*field type email
row 1	Last Name*field type single line Input blocked. Maximum character limit of 4000 characters reached.	First Name*field type single line Input blocked. Maximum character limit of 4000 characters reached.	Middle Namefield type single line Input blocked. Maximum character limit of 4000 characters reached.	Email*field type email

	Primary Phone Number*field type single line	Phone Type*field type drop-down
row 1	Primary Phone Number*field type single line Input blocked. Maximum character limit of 4000 characters reached.	Phone Type*field type drop-down

Address

	Street*field type single line	Apt/PO Boxfield type single line	City*field type single line	State*field type single line	Zip*field type number
row 1	Street*field type single line Input blocked. Maximum character limit of 255 characters reached.	Apt/PO Boxfield type single line Input blocked. Maximum character limit of 4000 characters reached.	City*field type single line Input blocked. Maximum character limit of 4000 characters reached.	State*field type single line Input blocked. Maximum character limit of 2 characters reached.	Zip*field type number

If you are related to a child in the school, please list below:

	Name of Childfield type single line	Gradefield type number	Teacherfield type single line	Relationship to Childfield type single line
Row 1×	Name of Childfield type single line Input blocked. Maximum character limit of 4000 characters reached.	Gradefield type number	Teacherfield type single line Input blocked. Maximum character limit of 4000 characters reached.	Relationship to Childfield type single line Input blocked. Maximum character limit of 4000 characters reached.	×

Add Enrolled Child

Please list two people to notify in case of emergency:

	Namefield type single line	Phone Numberfield type single line
row 1	Namefield type single line Input blocked. Maximum character limit of 4000 characters reached.	Phone Numberfield type single line Input blocked. Maximum character limit of 4000 characters reached.
row 2	Namefield type single line Input blocked. Maximum character limit of 4000 characters reached.	Phone Numberfield type single line Input blocked. Maximum character limit of 4000 characters reached.

Volunteer Agreement
I have requested authorization to service as a volunteer worker without pay for the Chico Unified School District. I certify that I am qualified to serve in the above capacity and classification as a safe worker due to prior experience and training.
The Undersigned hereby voluntarily releases, discharges, waives and relinquishes any and all actions or causes of action for property damage, personal injury, illness (including, but not limited to, COVID-19), or wrongful death occurring to him/herself arising as a result of engaging in said activity or any activities incidental thereto wherever or however the same may occur and continue, and the Undersigned does for him/herself, his/her heirs, executors, administrators and assigns hereby release, waive, discharge and relinquish any action or causes of action, aforesaid, which may hereafter arise for himself/herself and for his/her estate, and agrees that under no circumstances will he/she or his/her heirs, executors, administrators and assigns prosecute, present any claim for personal injury, property damage or wrongful death against the District or any of its officers, agents or employees for any of said causes of action, whether the same shall arise by the negligence of any of said persons, or otherwise.
IT IS THE INTENTION OF THE PARTICIPANT BY THIS INSTRUMENT, TO EXEMPT AND RELIEVE DISTRICT FROM LIABILITY FOR PERSONAL INJURY, PROPERTY DAMAGE OR WRONGFUL DEATH CAUSED BY NEGLIGENCE.
The undersigned, for himself/herself, his/her heirs, executors, administrators or assigns, agrees that in the event any claim for personal injury, property damage or wrongful death shall be prosecuted against the District, he/she shall indemnify and save harmless the same District from any and all claims or causes of action by whomever or wherever made or presented for personal injuries, property damage or wrongful death.

The undersigned acknowledges that he/she has read the foregoing three (3) paragraphs, has been fully and completely advised of the potential dangers incidental to engaging in the activity described above, and is fully aware of the legal consequences of signing the within instrument.
Signature*field type signature
Signature (Applicant)
Date*field type date
Date will be captured on form submission
By signing, I certify that I have provided accurate information and truthfully completed this form.

Affidavit Affirming No Criminal Record
I hereby certify that I have not been charged with or convicted of a violent or serious felony as defined in California Education code 45122.1. I understand that for the purposes of this affidavit, a person is deemed to be arrested and/or convicted of committing a felony or misdemeanor if such person has been arrested or convicted under the laws of any state, the United States, or any territory subject to the jurisdiction of the United States. In addition, I understand that convicted means a conviction by a jury or court and also includes the forfeiture of any bail, bond, or other security deposited to secure the appearance by a person charged with a felony or misdemeanor, the payment of a fine, a plea of nolo contendere, and the imposition of a deferred or suspended sentence by the court.

I declare under penalty of perjury that the foregoing is true and correct.
Signature*field type signature
Signature (Applicant)
Date*field type date
Date will be captured on form submission

Chico Unified School District

Field Trip Driver Form
A. Private Vehicle Use Guidelines
Drivers and private vehicles being operated for Chico Unified School District purposes must meet or exceed the following guidelines:
1.      All drivers must be approved by the school or site administrator.
2.      The driver must be at least age 21 to drive for business purposes and age 25 if transporting students, possessing a valid California driver’s license, and have been continuously licensed for a minimum of 3 years.
3.       Driver must be free of any medical condition that may affect his/her ability to operate a vehicle.
4.       No alcohol or drugs will be consumed prior to, or while operating the vehicle.
5.       The vehicle will be in excellent condition and repair.
6.       The number of passengers shall not exceed the capacity for which the vehicle was designed.
7.       No one may transport more than nine passengers plus the driver in any vehicle.
8.      All occupants must wear seat belts whenever the vehicle is in motion.
9.   All students who are less than 8 years of age or under 4’9” tall must be properly secured in a rear seat, in a child passenger restraint system, meeting applicable federal motor vehicle safety standards.
10.    The use of cell phones, pagers, or other electronic devices while driving is prohibited.
11.    Smoking a pipe, cigar or cigarette in the vehicle is prohibited.
12.    The driver accepts the added responsibility that comes from carrying extra individuals and, therefore, will be conscientious in obeying all driving rules and regulations in accordance with federal, state and local laws. The California Supreme Court has eliminated the protection of the former California Guest Law; therefore, a guest passenger may sue his/her host owner/driver.
13.    The driver must have an acceptable driving record as determined by the Chico Unified School District policy. The Chico Unified School District reserves the right to require a current K-4 Driver Records and/or accident reports for determination of driver eligibility.

14.    Driver must have an automobile liability insurance policy and assume all responsibility for all physical damage to the vehicle. When driving a personal vehicle while on Chico Unified School District business and involved in an accident, by law your liability insurance policy is used first. The Chico Unified School District liability policy would be used only after your policy limits have been exceeded.
Minimum liability limits of insurance required are:
15. If the above conditions change and/or cannot be met, I will no longer participate as a driver until the requirements can be met.
*field type checkbox
Yes, I have read the CUSD Private Vehicle Use Guidelines

B. Private Vehicle and Driver Information

Driver's License Information

	License Number*field type single line	Expiration Date*field type single line
row 1	License Number*field type single line Input blocked. Maximum character limit of 20 characters reached.	Expiration Date*field type single line Input blocked. Maximum character limit of 4000 characters reached.

Vehicle Information
Owner's Name*field type single line
Input blocked. Maximum character limit of 4000 characters reached.

Owner's Address

	Street*field type single line	Apt/PO Boxfield type single line	City*field type single line	State*field type single line	Zip*field type number
row 1	Street*field type single line Input blocked. Maximum character limit of 255 characters reached.	Apt/PO Boxfield type single line Input blocked. Maximum character limit of 4000 characters reached.	City*field type single line Input blocked. Maximum character limit of 4000 characters reached.	State*field type single line Input blocked. Maximum character limit of 2 characters reached.	Zip*field type number

Vehicle Details

	Make*field type single line	Year*field type single line	License Plate Number*field type single line	Registration Expiration*field type single line	Number of Seatbelts*field type number	Number of Booster/Child Restraintsfield type number
row 1	Make*field type single line Input blocked. Maximum character limit of 4000 characters reached.	Year*field type single line Input blocked. Maximum character limit of 4000 characters reached.	License Plate Number*field type single line Input blocked. Maximum character limit of 8 characters reached.	Registration Expiration*field type single line Input blocked. Maximum character limit of 4000 characters reached.	Number of Seatbelts*field type number	Number of Booster/Child Restraintsfield type number (if applicable)

Driving Record
*field type radio button
Have you had a valid California Driver's License during the past past 3 years?
YesNo
*field type radio button
Based on the Driving Record Table below, does your driving record meet the criteria of an "Acceptable Drive"?
YesNo

Minor Violations (within past 3 Years) include any moving violation that is not a major/serious violation as shown in this Table. (Examples of minor violations include, but are not limited to speeding, failure to yield, illegal passing, stop sign/light violation, improper turn, following too close, any other moving violation where DMV points are assessed).
Number of Minor Violations Within Last 3 Years	Number of At-Fault Accidents Within Last 3 Years
	0	1	2		3 or more
0	Acceptable	Acceptable	Borderline		Unacceptable
1	Acceptable	Acceptable	Borderline		Unacceptable
2	Acceptable	Borderline	Unacceptable		Unacceptable
3 or more	Unacceptable	Unacceptable	Unacceptable		Unacceptable
License Suspension or Revocation (within past 3 Years)				Unacceptable
Major/Serious Violations (within past 5 Years) · Failure to stop in the event of an accident (Hit and Run) · Driving under the influence of alcohol or drugs or with open container · Refusing to take a substance/chemical test · More than one dismissal of a conviction relating to controlled substances · Reckless/Careless Driving · Homicide or Manslaughter or using vehicle in connection with a felony · Evading a Peace Officer or resisting arrest · Driving the wrong way or in the incorrect lane on a divided highway · Driving in excess of 100 mph · Racing/Speed contests · Passing a stopped school bus				Unacceptable

C. Insurance Information for Vehicle Listed

	Insurance Company*field type single line	Policy Number*field type single line	Expiration Date*field type single line
row 1	Insurance Company*field type single line Input blocked. Maximum character limit of 4000 characters reached.	Policy Number*field type single line Input blocked. Maximum character limit of 4000 characters reached.	Expiration Date*field type single line Input blocked. Maximum character limit of 4000 characters reached.

Combined Single Limit?field type checkbox
If you have a Combined Single Limit check here
Combined Single Limit?Yes
Bodily Injury Limit $*field type number field type number
row 1 Bodily Injury Limit $*field type number
(Min. $100K each person)
field type number
(Min. $300K each occurrence)
Add
Property Damage Limit $*field type number
(Min. $50K each occurrence)
Combined Bodily Injury and Property Damage Liability*field type number
Combined Single Limit $(Min. 300K each occurrence)

	Bodily Injury Limit $*field type number	field type number
row 1	Bodily Injury Limit $*field type number (Min. $100K each person)	field type number (Min. $300K each occurrence)

D. Acknowledgments
Driver Acknowledgment
I certify the above information is correct and agree to advise the Chico Unified School District or School Name, in writing, of any changes in the above information. I have read and understand the Private Vehicle Use Guidelines.
Driver's Name*field type single line
Input blocked. Maximum character limit of 4000 characters reached.
Driver's Signature*field type signature
Date*field type date
Date will be captured on form submission
Registered Owner Acknowledgment
As the registered owner, I certify the above insurance information is correct. I understand I must have liability insurance coverage in force, as set forth above, and agree to advise the Chico Unified School District, in writing, of any changes in the above information. I further certify that to the best of my knowledge, the above vehicle is mechanically safe. If an accident occurs, my auto liability policy is primary and used first for losses or claim for damage. The Chico Unified School District does not cover, nor is it responsible for, comprehensive and collision (physical damage) coverage to my vehicle.
Vehicle Owner's Name*field type single line
Input blocked. Maximum character limit of 4000 characters reached.
Vehicle Owner's Signature*field type signature
Date*field type date
Date will be captured on form submission

CUSD Application for Volunteer Services

School Info

Volunteer Info

Address

If you are related to a child in the school, please list below:

Please list two people to notify in case of emergency:

Driver's License Information

Owner's Address