STUDENT DRIVER PERMISSION APPLICATION

Student Name: _____________________________________________

Driver’s License #: ___________________________________________

(copy of driver’s license must be attached to application)

Vehicle Type:                        1. ___________________________________

                                    2. ___________________________________

Vehicle Plate #:        1. ____________________________________

                                    2. ____________________________________

Registration #:          1. ____________________________________

                                    2. ____________________________________

Insurance Carrier Name: _________________________________________

Insurance Policy #:  _________________________________________

Effective Date of Coverage:            ___________________________________

I understand the following:

            1).       No other students may ride to or from school functions with me without permission and notes from both your parents and the rider’s parents.

.

            2).       Driving privileges may be suspended for any of the following reasons:

                        a.         Lack of parking space.

                        b.        Academic decline.

                        c.         Tardiness.

                        d.        Behavior problems.

            3).       I park in the school lot at my own risk.

__________________________                                            ___________________

Student’s Signature                                                             Date

__________________________                                            ___________________

Parent/Guardian Signature                                                           Date 

_____________________                                    _______________

H.S. Principals’ Signature                                                  Date