Placer Bus Group Discipline
and Medical Treatment Authorization Form
form may be found at www.PlacerBusGroup.com
passenger safety on the bus is imperative, students must accept
the absolute authority of the bus driver over
the operation of the bus.
The bus driver
will issue a written Incident Report describing the student’s
may result in a warning or suspension from the bus for
one or two full days.
Report must be signed by the parent or guardian, and returned to
the bus driver before the student can re-board the bus.
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
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
decision in issuing an Incident Report is final.
By signing below,
I have read the Discipline Policy Agreement, and will abide by its
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.
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
the cost of
any service or treatment provided. Health Insurance Company/Policy Number:
Signature: ____________________Parent/Guardian Signature: ________________
Print Student Name:
Print Parent Name:
to: 1 (916) 787-1151 -or-
PO Box 7247
Auburn, CA 95603
may fill in the information before you print this form. This
form must be mailed or faxed to the Placer Bus Group.