Student Organizations

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.

required date field

Today's Date*

Please enter today's date.

required text field

Driver's Full Name*

Please enter your full name.

required text field

Driver's Cell Phone Number*

Please enter your cell phone number.

required e-mail address field

Driver's L&C Email Address*

Please enter your L&C email address.

required text field

Driver's Driver Licence State and Number*

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

required text field

Driver's Insurance Carrier*

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

required text field

Driver's Insurance Policy Number*

Please enter your insurance policy number(s).

required text field

Vehicle Make*

Please enter the make for your vehicle.

required text field

Vehicle Model*

Please enter your vehicle's model.

required text field

Vehicle State and License Plate Number*

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

required checkbox field

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.

required checkbox field

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.

required checkbox field

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.

Link (required)

Student Organizations

Contact Us

187

Office of Student Activities is located in room 258 of the second floor of Templeton Campus Center on the Undergraduate Campus.

email activities@lclark.edu

voice 503-768-7122

Director of Student Activities Jason Feiner

Office of Student Activities

0615 S.W. Palatine Hill Road, MSC 187
Portland, Oregon 97219