STUDENT DEVELOPMENT VEHICLE REQUESTS RESERVING UNIVERSITY VANS 1. Fill out the packet and submit ONE WEEK PRIOR to your trip. Forms can be dropped off at 214 Dougherty. a. The first page must be completed and submitted ASAP by the driver. i. The driver must be certified by Public Safety ii. Your advisor must also sign this page as well b. On the second page, list all of the names of the students who will be riding in the van, along with their emergency contact information. i. This list is required by Financial Affairs for University Insurance records. c. The third page is a trip waiver that must be signed by all of the students traveling in a university vehicle. 2. Once your reservation has been submitted and approved by Student Development, ONLY the assigned driver can take their van confirmation and driver’s license to the Public Safety Office at Farrell Hall and pick up van keys. 3. If your group, class or office is using a university van for the first time, please make sure that Amber Grier has the account number that van mileage should be charged to. VAN CHARGES Accounts that are submitted for van reservation(s) will be charged $.32 per mile Departments and/or offices that did not contribute vans into the van fleet pool will be charged an additional $25 per van request. REMEMBER: Bring your van confirmation and driver’s license when picking up van keys Keys must be returned to Farrell Hall at the end of your trip Vehicles must be returned to the designated parking area (back of West Main Parking Lot) Van reservations must be cancelled at least 24 hours in advance or you will be charged a cancellation fee of $10. One violation will result in loss of van privileges for one month. Second violation will result in loss of van privileges for the semester. Questions? Contact Amber Grier at 610-519-4210 or at amber.grier@villanova.edu Van cancellations after 5pm, call 610-519-6998 or 6992 OFFICE OF STUDENT DEVELOPMENT VAN REQUEST FORM Organization ____________________________________________________________ Account Number_________________________________________________________ Date/Dates Requested _____________________________________________________ Destination______________________________________________________________ Purpose of Trip __________________________________________________________ 7 or 12 Passenger Van ____________________________________________________ Pick-up/Return time of van_________________________________________________ Name of Certified Driver ___________________________________________________ Driver’s Cell Phone/E-mail_________________________________________________ DRIVER PLEASE READ THE FOLLOWING STATEMENTS; SIGNING BELOW CONFIRMS AGREEMENT: I understand that the van must be returned to the West Main parking lot. I understand that the keys for the van must be returned to Farrell Hall I understand that I am responsible for returning the van with a minimum quarter tank full of gas. I understand that the interior of the van must be clean upon return. I understand that if the van is involved in an accident/incident, I will report it immediately to Villanova Public Safety and the Office of Student Development. I understand that if the van and keys are not returned on time, my group will lose van privileges. I confirm that I have passed the University’s driver certification program, have submitted a Motor Vehicle Report Consent Form, and registered as a driver at villanova.agilefleet.com. _____________________________________________ __________________ Signature of Certified Driver Date _____________________________________________ Advisor Name (Printed) _____________________________________________ __________________ Signature of Advisor Date NAME LOCAL ADDRESS PERSON TO CONTACT IN EMERGENCY CONTACT PHONE VILLANOVA UNIVERSITY ASSUMPTION OF RISK AND RELEASE FIELD TRIPS AND OFF-CAMPUS ACTIVITIES VILLANOVA UNIVERSITY CLUB FIELD TRIP AND OFF-CAMPUS ACTIVITIES WAIVER AND ASSUMPTION OF RISK I, the undersigned, desire to participate in the ___________________________________ Club (the “Club”), a voluntary activity sponsored by Villanova University, during the Fall/Spring semester of 2013-2014. As part of the Club activities, I understand that I will be traveling to and from various locations in University vehicles. In return for being permitted to participate in the Club, and understanding that there are certain risks associated with such Club activities and in traveling to and from various locations in connection with such Club activities (together “the Activities”), and intending to be legally bound hereby, I the UNDERSIGNED, for myself, my assigns and legal representatives hereby agree to: 1. RELEASE, WAIVE, DISCHARGE AND AGREE NOT TO SUE, Villanova University, its successors, assigns, affiliates, officers, directors, employees and agents from all manner of actions and causes of action, suits, debts, judgments, claims and demands whatsoever in law or equity, including all claims for personal injury or property damage arising in any way out of my participation in the Activities. 2. ASSUME ANY AND ALL RISKS arising from my participation in the Activities, including, without limitation, the risks of death, bodily injury or property damage, the unavailability of emergency medical care or the negligent or deliberate act of another person. 3. INDEMNIFY, DEFEND AND HOLD VILLANOVA UNVERSITY and its officers and employees and agents harmless from, any and all claims, cause of action, damages, judgments, costs or expenses, including attorney’s fees, whatsoever, arising from my participation in the Activities. 4. I certify that I have no medical condition that would preclude or restrict my participation in the Activities and that I have adequate health insurance protection to cover the expense of any unforeseen accident or injury. I recognize that Villanova University does not carry or maintain health, medical or disability insurance coverage for my participation in the Activities and is not obligated to attend to any of my medical or medication needs; I assume all risk and responsibility therefore. 5. I further acknowledge that Villanova University does not carry property insurance that applies to theft or loss of my personal property in connection with the Activities. I understand that University will not be responsible for any physical damage to or theft or loss of my personal belongings in connection with the Activities. 6. I acknowledge that I have read and understand this WAIVER and that by signing it I surrender valuable rights, which I have done freely and voluntarily. PRINTED NAME: SIGNATURE: DATE: PARENT NAME: (If participant is under 18) PARENT SIGNATURE and DATE: