PRIORY ATHLETICS DRIVER'S REGISTRATION
LICENSE AND VEHICLE INSURANCE INFORMATION
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I. Driver Information
Please complete all boxes
Driver's First Name *
Driver's Last name *
Driver's Address *
street, city, zip
Driver's Cell Phone Number *
Relationship with student *
How many passengers can your vehicle carry? *
A seat belt is required for each passenger.
II. Certification
In accordance with Priory Athletics Policy, approval is requested to use a privately owned automobile to transport athletes to athletic events.

     1.  I certify that my privately owned vehicle will always be:            
          a.  Covered by liability insurance for the minimum amount prescribed by the Priory:
               $300,000 single limit or $100,000/$300,000/$25,000 automobile liability insurance with Uninsured/Underinsured coverage.
          b.  Equipped with one fully functional seat belt for every passenger.
          c.  To the best of my knowledge, in safe mechanical condition and adequate for passenger transportation.

     2.  I further certify that while using my privately owned vehicle for transportation of Priory athletes, all motor vehicle laws will be obeyed, including all passengers’       use of seat belts.

Note:  Any traffic accidents, no matter how minor, will be reported immediately to athletic director. (650) 743-7258

     3.  I further certify that I have not been convicted of Driving Under the Influence, Driving While Impaired or Reckless Driving in the past five years.

     4.  I further certify that I am at least 21 years old, and that I possess a valid Driver’s license as follows:

 
Driver's License Number *
Driver's License State *
Driver's License Expiration Date *
mm/dd/yyyy
Driver's Date of Birth *
mm/dd/yyyy
III. Proof of Insurance
Insurance Company *
Policy Number *
Policy Expiration Date *
mm/dd/yyyy
Electronic Signature
By entering my name below, I understand that I am providing an electronic signature which will serve as authorization and verification of the accuracy and completeness of the information I have provided.
First Name *
Last name *
Date Signed *
mm/dd/yyyy
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