BURGETTSTOWN HIGH SCHOOL

STUDENT DRIVING APPLICATION

Name: ______________________________________________ GRADE: __________

Vehicle 1: Make _____________________ Model: ________________ Year: ______

Color: _________ License Plate #: ____________

Insurance Carrier: __________________ Policy #: _____________________

Vehicle 2: Make _____________________ Model: ________________ Year: ______

Color: ___________ License Plate #: ____________

Insurance Carrier: __________________ Policy #: _______________________

Student(s) permitted to ride with this driver.

Name: _____________________________ Parent Signature: _____________________

of Driver
Name: _____________________________ Parent Signature: _____________________
of Driver
Name: _____________________________ Parent Signature: _____________________
of Driver

I hereby signify that I have read and understand all the rules and regulations governing
student driving. I further agree to assume all responsibility for my son/daughter
______________ driving the above listed vehicle(s) to school and understand that he/she
will lose this privilege if school driving regulations are violated. I further understand the
District policy related to vehicle searches and authorize such searches upon reasonable
suspicion that illegal or contraband substances may be present.

_____________________ ____________________________ _____________

Student Signature Parent Signature Date

Office use only: Date Rec’d: __________________ Permit #:___________

Payment Cash ______ Check #_______

revised 8/13/18