/ Student Engagement/ Vehicle Owner/Driver Acceptance of Responsibility Form

Vehicle Owner/Driver Acceptance of Responsibility Form

Please complete this form if you plan on driving your personal vehicle for any activity for your student organization. Please note that drivers must be cleared by Facilities Service in order to be eligible for reimbursement for mileage and/or gasoline.

As the insured owner/driver of the vehicle listed below, I understand and will adhere to all “rules of the road,” and will adhere to the policies with regards to travel identified by Lewis & Clark College. I also acknowledge that Lewis & Clark College does not provide insurance for the vehicle and/or its owner, driver, or occupants and is not liable for personal injury or property damage. As the owner/driver of the vehicle listed below, I understand that I may be exposing myself to personal liability in the event of an accident.

All fields marked with asterisk (*) are required.

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Today's Date*

Please enter today's date.

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Driver's Full Name*

Please enter your full name.

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Driver's Cell Phone Number*

Please enter your cell phone number.

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Driver's L&C Email Address*

Please enter your L&C email address.

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Driver's Driver Licence State and Number*

Please enter the state that your driver license is from and its number.

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Driver's Insurance Carrier*

Please enter the name of the company that your car insurance is from.

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Driver's Insurance Policy Number*

Please enter your insurance policy number(s).

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Vehicle Make*

Please enter the make for your vehicle.

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Vehicle Model*

Please enter your vehicle's model.

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Vehicle State and License Plate Number*

Please enter the state that your vehicle is from and its licence plate number.

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Release*

To the fullest extent permitted by law, I shall defend, indemnify, and hold harmless Lewis & Clark College, its trustees, officers, employees, students, and representatives from and against any and all loss, expense, damage, claim, demand, judgment, fine, charge, lien, liability, action, cause of action or proceedings of any kind whatsoever (whether arising on account of damage to or loss of property, or personal injury, emotional distress, or death) arising directly or indirectly in connection with the use of my personal vehicle, whether the same arises before or after the use of my personal vehicle.

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Insurance Verification*

I certify that I have the necessary minimum liability insurance coverage for passenger vehicles as required by the state in which my vehicle is registered.

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Electronic Signature*

I certify that I am submitting this information to the best of my knowledge and understand that I will be contacted by Student Activities to review this submission.

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