ELLS
IDDLE
CHOOL
“Home of the Roadrunners”
A California Distinguished School
Dear School Volunteer:
Volunteers provide key support for our students. Thank you for your interest in volunteering at our school. The Dublin Unified School District has
implemented an annual screening process for all that wish to volunteer their services.
The purpose of this annual screening is to ensure that no one working with our children has a record of sexual misconduct, thus providing a safe and
positive environment in our classrooms and activities. Once it has been determined that the potential volunteer has not been identified on the Megan’s
Law list, the principal or designee will approve your request to volunteer.
For drivers:
1. The Dublin School District carries liability insurance covering all school-sponsored activities. In the event of a vehicular accident, however,
coverage is provided by the volunteer driver’s own automobile insurance.
2.
The school district does not provide insurance coverage should a vehicular accident occur while a volunteer driver is transporting students.
3.
Volunteer drivers must be at least 21 years of age and must possess a current, valid California driver’s license to operate this vehicle.
4.
Volunteer drivers certify that their vehicle is in safe operating condition.
5.
Volunteer drivers and/or the owner for the vehicle have primary responsibility for liability. The liability insurance of the volunteer drivers will
be deemed the primary liability insurance for claims purposes.
6.
Volunteer drivers agree to dive in a safe and cautious manner and to notify the school district immediately in the event of accident or injury
of any type.
7.
Volunteer drivers shall have a first aid kit in their possession, or immediately available.
8.
Volunteer drivers will carry no more passengers than their vehicle is designed to carry. In no case may a volunteer driver carry more than
eight passengers plus the driver.
9.
Volunteer drivers offering to provide transportation for students for one or more school sponsored field trips during the school year
acknowledge their responsibilities as indicated in this notice and will acknowledge receipt by signing and returning a copy of the notice.
10. The District reserves the right to decline offers of assistance from parents, guardians, and other volunteers, including but not limited to driving.
11. Volunteer driver, by their signature on the Transportation Authorization Form, waive all claims against the District for injury, accident, illness,
or death occurring during or by reason of the field trip.
12. Volunteer drivers shall defend and indemnify the District against all claims, actions, or lawsuits arising out of the negligence of the volunteer
driver.
Thank you for your cooperation, understanding and support of the District’s desire to keep our students and school safe.

Copy of CDL Attached

Proof of Insurance Attached
Insurance Expiration Date: ____________
DUBLIN UNIFIED SCHOOL DISTRICT TRANSPORTATION OF
STUDENTS IN PRIVATELY OWNED VEHICLES*
Certificate and Authorization for PARENT/GUARDIAN(S)*
WELLS MIDDLE SCHOOL
I have agreed to use my privately owned automobile for transporting students to school related activities. I certify that I possess a valid California
Driver’s License and presently have in force, automobile liability insurance coverage. I also accept the terms of the Indemnity Provision stated below.
Names(s) of DUSD Students: __________________________________________________________________________________________
Name of Driver: ____________________________________________ Driver’s License No.: _______________________________________
Address of Driver: ____________________________________________ Main Phone No.: ________________________________________
Make of Automobile: __________________________________________ Year/Model/Style: ________________________________________
Automobile License No.: ______________________________Passenger Capacity w/Driver: ________________________________________
Name of Insurance Company: _________________________________________ Policy No.: _______________________________________
SEAT BELTS REQUIRED TO BE USED BY ALL OCCUPANTS
(NEW LAW AS OF JANUARY 2012)
ALL STUDENTS MUST BE AT LEAST 4 FOOT 9 INCHES TALL or 8 YEARS OF AGE
OR THEY MUST BE PLACED IN A CHILD BOOSTER SEAT
STUDENTS UNDER THE AGE OF 12 ARE NOT PERMITTED TO RIDE IN FRONT SEAT IF AIRBAG IS INSTALLED IN VEHICLE
PLEASE ATTACH A COPY OF INSURANCE COVERAGE DECLARATION PAGE TO THIS FORM
I have met the minimum insurance requirements per
occurrence as listed below or have umbrella coverage
of at least $500,000:
Bodily Injury Liability (BI):
Each Individual
$100,000
Total Each Accident
$300,000
Property Damage Liability (PD):
Total Each Accident
$25,000
or Combined Single Limit (BI & PD): $300,000
Medical Payments:
Each Individual
$5,000
Uninsured Motorist Coverage (UIM):
Each Individual
$100,000
Total Each Accident
$300,000
FOR SCHOOL USE ONLY
Authorized by Responsible School Official
Approved by:
_____________________________________
Signature
__________________________________
Date
Parent/guardian(s) should be aware that although there is a liability insurance policy in the District, it is the individual driver’s own auto
liability insurance that must provide the coverage in case of an accident. See Insurance Code 11580.1.
Please obtain a Report of Accident form from school office prior to departure.
* INDEMNITY PROVISION *
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

Student drivers shall not transport other students on authorized field trips.
The owner/driver agrees and accepts his/her obligation to operate, manage and control his/her vehicle in a safe and lawful manner while
transporting students, pursuant to this certificate and authorization.
The owner/driver further agrees to defend and indemnify the Dublin Unified School District from any claim, action or lawsuit brought by anyone
which arises out of, or is in any way connected to the operation of the vehicle, pursuant to this certificate and authorization.
________________________________________ Date __________________________________________________ Signature of Owner/Driver
DUBLIN UNIFIED SCHOOL DISTRICT
Volunteer Information Form
Authorization for Parent/Guardian
WELLS MIDDLE SCHOOL
California Education Code Section 35021 requires school districts to screen school volunteers. In order to complete the screening, please provide the
information requested below.
Name of Student ____________________________________________________________________________________________________
Name of Volunteer ___________________________________________________________________________________________________
Last
First
Middle
Other Name
Address: __________________________________________________________ City/Zip: ________________________________________
Telephone: _______________________________________________ Telephone: _______________________________________________
Home
Date of Birth: _________________
Work or Cell
Driver’s License #: ____________________________
or State ID #: ______________________
(attach photocopy)
(attach photocopy)
EMERGENCY CONTACT
Name: __________________________________
Relationship: _________________________ Phone/Cell #: ______________________
Name: __________________________________
Relationship: _________________________ Phone/Cell #: ______________________
REFERENCES (List 2 people who are not related to you who have knowledge of your character or work experience)
Name: __________________________________
Relationship: _________________________ Phone/Cell #: ______________________
Name: __________________________________
Relationship: _________________________ Phone/Cell #: ______________________
FOR COLLEGE STUDENT VOLUNTEERS
________________________________________
_____________________________________ or ________________________________
College/University Name
College/University ID
Verification of Enrollment
I agree and understand that it’s my responsibility to notify the school administration of any status change in my driver’s license if I volunteer to drive.
The approval to volunteer will be based on the clearance of the background check on Megan’s Law list and approval of the principal or designee.
Signature ________________________________________________________________________ Date ______________________________
TO BE COMPLETED BY SITE ADMINISTRATOR/DESIGNEE
Volunteer Assignments Cleared for:
 Classroom volunteer
 Driver*
 School Activities/Fundraisers
 Outdoor Education/Overnight **
 Other
Certificated Supervisor: ___________________________________________________________
Date: _____________________
Principal/Designee: ______________________________________________________________
Date: _____________________
* Driver clearance requires submission of valid copy of driver’s license, proof of current auto insurance which reflects driving record,
i.e points; OR valid copy of driver’s license. Driving records with more than one point will not receive clearance to drive. Drivers will
need to complete the Transportation of Students Authorization Form attached.
** Activity requires Livescan fingerprint clearance.