EEAG/IICA-R Use of Private Vehicle Form


ConVal School District

Use of Private Vehicle Form

All drivers transporting Contoocook Valley School District students to and from curriculum and extra-curricular activities must follow the minimum requirements and provide an original document* (for photocopying items 1-3) and indicate confirmation of items 4 & 5:

  1. Valid Driver’s License*.
  2. Current Motor Vehicle Registration*.
  3. Current State approved automobile insurance* providing minimum liability coverage of $300,000 in the event of an accident.  It must be understood that the required insurance is the minimum and represents the primary insurance on the vehicle and occupants.
  4. Current Motor Vehicle Inspection   _____YES            _____ NO
  5. At least one working seat belt per vehicle occupant.    _____ YES        _____ NO

As the driver of this vehicle, I will transport _________# of students, from ________________________ to

______________________________________  on ________________ and return.

Photocopies of the following documents have been recorded (completed by school):

(Please resubmit if information changes)

Current Motor Vehicle Registration*              _____  YES     _____  NO

Current State-Approved Auto Insurance       _____  YES     _____  NO

Valid Driver’s License                                    _____  YES     _____  NO

In addition, all drivers must adhere to the following:

a. Drivers must ensure that all passengers are properly seated and secured by seat belts and child restraints as required by state law. Younger students will be seated in the rear seat of the vehicle.  The on/off switch for passenger side air bags will be set to manufacturer’s safety specifications.

b. Drivers will not use hand held communication devices such as, but not limited to, cell phones while operating a moving vehicle.  In the event any of these devices are needed to be used, park the vehicle.

c. Smoking is prohibited in the presence of students.

I state from personal review and knowledge that the above vehicle meets all minimum requirements as identified in items 1-5 above and will comply with the above-mentioned a, b, and c.


Driver: ______________________________________   Date: ____________________


Printed Name: __________________________________________________________


Received by: _________________________________   Date: ____________________

Principal or designee 



Updated May 2019