Placer Bus Group Discipline Policy Agreement
and Medical Treatment Authorization Form
This form may be found at

Because passenger safety on the bus is imperative, students must accept the absolute authority of the bus driver over during the operation of the bus.

  1. The bus driver will issue a written Incident Report describing the student’s misconduct.
  2. Each offense may result in a warning or suspension from the bus for one or two full days.
  3. Each Incident Report must be signed by the parent or guardian, and returned to the bus driver before the student can re-board the bus.
  4. Student refusal to accept the driver’s Incident Report will result in a five (5) day suspension for the offense. In such an event, the Incident Report will be sent by mail to the parent or guardian.
  5. A third suspendable incident during a school year may result in expulsion from the bus group. Notification of this action will again be done by mail.
  6. The driver’s decision in issuing an Incident Report is final.

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 Auburn and Sacramento, with a stop at Rocklin, and Roseville to and 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 registered 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:
 Emergency Phone:                      Date:       rev 5/09
Fax to: 1 (916) 787-1151 -or- mail to:  

Placer Bus Group
PO Box 7247
Auburn, CA 95603
You may fill in the information before you print this form. This form must be mailed or faxed to the Placer Bus Group.