Placer Bus
Group Occasional Rider Agreement
and Medical Treatment Authorization Form
This
form may be found at www.PlacerBusGroup.com
A copy of this form and $5.00 (exact change, no coins) must
be give to the bus driver each time a ride is requested. Ridership
is limited to afternoons
only to Roseville, Rocklin and Auburn and transportation
is not guaranteed if there is no room on the bus or if the properly
signed form and money is not presented upon boarding.
By signing below,
I have read the Discipline Policy Agreement, and will abide by its
terms
and
those
that are contained in the Terms and Policies of the
Placer Bus Group.
*********************************************************
My child, has my permission to ride the bus operated by Placer Bus Group
(PBG) between Sacramento and Auburn, with a stop at Rocklin and Roseville, from
St. Francis and/or Jesuit high schools. If, in the judgment of the bus driver,
a medical need arises the bus driver is authorized to consent to the following
medical treatment:
Any X-ray examination, anesthetic, medical or surgical diagnosis or
treatment, and hospital care which is deemed advisable by, and is to
be rendered under the general or special supervision of any physician
and/or surgeon licensed under the provisions of the Medical Practices
Act, California Business and Professions Code section 2000 et seq.; or
any X-ray examination, anesthetic, dental or surgical diagnosis or treatment,
and hospital care to be rendered by a dentist licensed under the provisions
of the Dental Practices Act, California Business and Professions Code
section 1600 et seq.
This authorization
shall remain effective as long a my child is a occasional bus rider unless
sooner revoked in writing. I understand that as a parent/legal guardian,
I will be responsible for the cost of any service or treatment provided.
Health Insurance Company/Policy Number:
You
may fill in the information before you print this form. This properly
signed form must be given to the bus driver each time transportation
is requested. It will not be returned to the rider.