Placer Bus Group Occasional Rider Agreement
and Medical Treatment Authorization Form
This form may be found at www.PlacerBusGroup.com/ora

A copy of this form and $10.00 (exact change, no coins) must be give to the bus driver each time a ride is requested. Ridership is limited to mornings and afternoons to/from 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.
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My child has my permission to ride the bus operated by Placer Bus Group (PBG) within Placer and Sacramento Counties servicing St. Francis, Jesuit and occasionally Cristo Rey 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:

Student Signature: ____________________Parent/Guardian Signature: ________________

Print Student Name: Print Parent Name:

Address, City, ZIP:  

Home/WorkEmergency Phone:  Date:       

Placer Bus Group
PO Box 7247
Auburn, CA 95603
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.

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