SAINT MATTHEW TEEN MINISTRIES MISSION // Shaping Young Disciples by inviting them to Meet Jesus, Form Friendships, and Serve Others by the power of the Holy Spirit
Purpose of Form
Transportation Certification and Authorization of children/youth in privately-owned vehicles

I have agreed to use my privately-owned automobile for the transportation of students to church-related activities. I certify that I have a valid California driver’s license and am 21 years of age or older. I also certify that my vehicle is properly registered and that I have, in force, automobile liability insurance in the amounts set out below. I certify that my vehicle is in safe operating condition. I also accept the terms of the indemnity provision below.

Driver's Name *
Date of Birth *
Driver's License # *
Street Address *
City, State & Zipcode
Phone Number *
Vehicle Information
Complete below using your vehicle information. If using rented vehicles, skip this section.
Year, Make and Model of Car
Auto License Plate #
Passenger Capacity (not including driver)
-Seat belts must be used by each occupant at all times.
-Children under 2 years of age shall ride in a rear-facing car seat unless the child weighs 40 or more pounds OR is 40 or more inches tall.
-Children under the age of 8 must be secured in a car seat or booster seat in the in the back seat.
-Children who are 8 years of age OR have reached 4'9" in height must be secured by a safely belt.
-Students under twelve may not ride in front seat of vehicles equipped with air bags.
-The vehicle’s rated capacity may not be exceeded.
-Student drivers may not transport other students on any trip.
-CA law prohibits smoking in a vehicle when a minor (17 or younger) is present.

I certify that I have met the minimum vehicle insurance requirements per occurrence as listed below.

Bodily Injury Liability: Each Individual - $100,000; Total Each Accident - $300,000.
Property Damage Liability: Total Each Accident - $25,000
Medical Payments Each Individual - $5,000
Uninsured Motorist Coverage: Each Individual - $30,000; Total Each Accident - $60,000
Combined Single Limit: $300,000; Medical Payments Each Individual - $5,000
Uninsured Motorist Coverage: Each Individual - $30,000; Total Each Accident - $60,000

Saint Matthew Lutheran Church does NOT provide insurance coverage for privately owned vehicles. I acknowledge, as vehicle owner, that I am responsible for all costs associated with any incident and/or accident and have consulted with my insurance carrier regarding insurance coverage. Vehicle owner agrees and accepts his/her obligation to manage and control his/her vehicle in a safe and lawful manner. Vehicle owner agrees to defend and indemnify Saint Matthew Lutheran Church, its employees, officers and agents from any claim, action or lawsuit brought by anyone that arises out of, or is in any way connected to, the operation of the owners of the private vehicle pursuant to this certificate and authorization.

ON THE DAY OF THE EVENT PLEASE CARRY WITH YOU YOUR DRIVER'S LICENSE AND PROOF OF INSURANCE. Thanks for your help in supporting the Teen Ministry and for keeping our teens safe!

I have read and approve of all the above and acknowledge my acceptance by inputting my name below.

Driver Volunteer E-Signature (please type name)
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