License No.:

Audit No.:

Date: 	

Form 430021
(06-16)

OFFICE OF DRIVER SERVICES

AFFIDAVIT FOR MINOR SCHOOL LICENSE

Eligibility requirements for Minor School License: The student must have an instruction permit for at least six months, must complete an Iowa-approved driver education course, and must have a clean driving record for at least six consecutive months immediately before applying for the minor school license and live one mile or more from the school, unless the school board determines a special need exists.

 	Section 1:  Student Information	

Student’s full name:
Student’s Iowa driver license number:

Student’s date of birth:
Student’s residential address (where student intends to drive from). Note: This address must be within the school district or a contiguous school district of the school that is listed in Section 2 below.
Address:

Optional -- Additional address for students whose parents are legally divorced or separated. This address must also be within the school district or a contiguous school district of the school listed in Section 2 below:
Additional Address that student intends to drive from:

*Please note that a student may not drive between two residential addresses. A student may drive to and from Address 1 and approved school classes/extracurricular activities listed below and to and from Address 2 and approved school classes/extracurricular activities listed below, but may not drive from one residential address to the other.

 	Section 2:  School Statement of Necessity	

This section must be completed by the school board chairperson, superintendent, or principal (if authorized by the superintendent) of the applicant’s school. Completion of this section does not render the school board chairperson, superintendent, or principal executing this section responsible for the driving acts performed by the student under any license granted.

Name of school:

I certify that:
the above named student (please check the box that applies) lives at least one mile from the school
the school board has otherwise determined a special need exists
a need exists for the above named student to obtain a minor school license to attend duly scheduled courses of instruction or extracurricular activities within the school district or within a contiguous school district if open enrollment under Chapter 282 applies, or to participate in extracurricular activities conducted within his/her district or within a contiguous district at a site or facility designated by the school district to accommodate extracurricular activities or within a contiguous district under a sharing agreement pursuant to Chapter 280;
the school listed above is an accredited school, or a school that uses licensed practitioners as instructors;
the duly scheduled courses of instruction are prescribed by the school board or required by statute, and the extracurricular activities are sponsored by the school board; and
the above named student has successfully completed an approved driver education course or qualifies for a driver education hardship exemption.

I certify under penalty of perjury and pursuant to the laws of the State of Iowa that the preceding is true and correct. The school board, superintendent, or principal if authorized by the superintendent, is not responsible for actions of the applicant which pertain to the use of the driver license.

Superintendent, Principal, or School Board Chairperson	Date

 	Section 3:  Parent/Guardian Consent and Certification	
Parent/Guardian name:
Parent/Guardian address:

Parent/Guardian driver license/ID number:
I certify that:
I am the parent, guardian, or legal custodian of the above named student and consent to the issuance of a minor school license for the purposes of attending duly scheduled courses of instruction or extracurricular activities within the school district or within a contiguous school district if open enrollment under Chapter 282 applies, or to participate in extracurricular activities conducted within his/her district or within a contiguous district at a site or facility designated by the school district to accommodate extracurricular activities or within a contiguous district under a sharing agreement pursuant to Chapter 280;

Minor Organ Donor: I	do	do not give my approval for the above-named minor applicant to be designated as an organ donor under the provisions of Chapter 142C.

I certify under penalty of perjury and pursuant to the laws of the State of Iowa that the preceding is true and correct.

Parent/Guardian	Date
 	Section 4:  Minor School License Requirements and Information	
Where can the student drive and at what times?
The student may drive without adult supervision between the hours of 5 a.m. and 10 p.m. for the following purposes:
Drive from home to school(s) of enrollment or school sponsored activities using the most direct and accessible route. Activities must be at the school(s) the student is enrolled in.
Drive to a school that is not their school of enrollment to participate in extracurricular activities. Activities must be in a contiguous (bordering) school district and must be held at a site, facility, or school designated for the activity under a sharing agreement between schools or conducted at a site or facility that the school district they are enrolled in has designated to accommodate extracurricular activities.
Drive to and from their home to the closest school bus stop.
Stop for fuel while on route or at the closest filling station off route.
The student may also drive at any time with adult supervision (same as instruction permit). Adult supervision means a parent, guardian, custodian, an immediate family member at least 21 years of age, a driver education instructor, or a person at least 25 years of age with written permission from parent, guardian, or custodian. The supervising adult must possess a valid driver’s license.

Passenger restriction
When driving without adult supervision, the student may only carry one minor passenger that is not a relative. A relative means someone that is the student’s brother, sister, step-brother, step-sister, or another minor living in their household.

No electronic communication devices
The student may not use a cell phone, smartphone, tablet, or other electronic communication or entertainment device while driving.

What happens if student gets a ticket/violation?
A minor school license will be suspended if the student is convicted of a traffic violation (including, but not limited to, speeding, reckless driving, failure to obey a traffic signal), violate any of the restrictions on the license, or is involved in a crash the student caused or contributed to.
First offense: license will be suspended for 30 days; $20 reinstatement fee
Second offense: license will be revoked for 30 days; $20 reinstatement fee; must reinstate to instruction permit for six months before the student is eligible for another minor school license.
Note : Any time the student has a violation, the six-month period to have a clean driving record will start over. Any time the student’s license is suspended or revoked, the 12-month period to hold an instruction permit (or combination of an instruction permit and minor school license) will start over.

Eligibility requirements to advance to Intermediate License
The next level of the graduated driver’s license program is an intermediate driver’s license. To obtain this license, applicants must be at least 16 years old and hold an instruction permit (or instruction permit then minor school license) for at least 12 consecutive months and maintain a clean driving record for at least six consecutive months immediately before applying for an intermediate license.
Intermediate driver’s license applicants must also complete 20 hours of supervised driving in addition to any driving completed in driver’s education. At least two of those hours must be between sunset and sunrise.

For more information about the Graduated Driver’s License Program for people under age 18, please visit http://www.iowadot.gov/ mvd/driverslicense/under18.html

Please bring this completed form along with the student’s driver’s education certificate of completion to any driver’s license issuance location to obtain the student’s Minor School License. The cost is $8.00.