Prior to submitting this form, please be sure:
you have read and understand the {{http://www.wm.edu/about/administration/senioradmin/adminoffice/riskmanagement/vehiclepolicy/general_responsibilities/index.php#IIIA, Driver Conduct Regulations}}
you have read and understand the College's {{http://www.wm.edu/about/administration/senioradmin/adminoffice/riskmanagement/vehiclepolicy/index.php, Vehicle Use Policy}}
Under the university's Vehicle Use Policy, you are required to complete a driver authorization form prior to driving:
1) a university vehicle or rental vehicle
OR
2) a personally-owned vehicle on an officially recognized Sport Club trip where you will be driving another student or seeking reimbursement.
The schedule for Van Safety classes may be found on the Student Activities website: {{http://www.wm.edu/offices/studentactivities/services/vansafety/index.php}}
Background Information:
Primary Sport Club :
Last Name:
First Name:
Additional Sport Club(s) you are a member of: please separate multiple clubs with a comma
Local Phone:
Cell Phone:
Email:
Status:
Age:
William and Mary Van Safety Training Course Date (Month/Year): Necessary to drive a college van or Enterprise rental vehicle.
Driving Information:
The following questions ask for information that you are obligated to update. If there is any change to any of the answers you provide below, you are required to notify the sport club coordinator promptly before driving to/from any recognized sport club events / practices. This means that you must tell us before driving a university van or taking another student(s) in your car for sport club travel if, for example:
you get a speeding ticket,
have an accident,
your license expires,
your inspection sticker expires
any other relevant driving history changes
1) Do you have a valid driver's license?:
Driver's License Issuing State:
Driver's License #:
2) Do you have valid automobile liability insurance?:
3) To your knowledge, is your personal vehicle in safe condition to drive? Answer only if you will be driving your personal vehicle for club activity.
4) Does your vehicle have a current and valid inspection sticker? Answer only if you will be driving your personal vehicle for club activity.
5) Have you had any moving violation in the past 5 years? Moving violations include speeding, reckless driving, and other traffic offenses other than parking tickets.
Indicate the date* and describe the nature of each violation: (i.e. whether it was for speeding, reckless driving, etc.) If, as a result of vehicle-related convictions, you are currently in a special-risk or other insurance pool, please note.
More Information about this question...
*Dates can be approximate, particularly for older incidents. For example, "January 2009" or "fall 2009" are acceptable.
6) Have you been in an accident as the driver of a vehicle in the past 5 years?:
Indicate the date(s) and briefly describe the nature of the accident. If the accident was minor (such as a fender-bender or other low-speed, low-damage incident), no further information is needed. For more significant accidents look at more info:
Give information relevant to the cause, such as whether you rear-ended another vehicle, were hit by a drunken driver, lost control while speeding, etc.
Unless another driver was clearly at fault, indicate if serious injuries resulted.
7) Have you been convicted of DUI or DWI or the equivalent* in the past 15 years?: *Different states use different terms for alcohol-related driving offenses, such as "OUI" (operating under the influence).
Indicate the date* and any other information you think relevant.
8) Has your license been suspended in the past 15 years?:
Indicate the date. Suspensions unrelated to driving, driver safety, alcohol, or drugs do not need to be reported. Suspensions for failure to pay court fines or child support are examples of reasons that do not need to be reported. Read more info.
Failure to pass a mental or physical exam, or to stop at the scene of an accident, are examples of reasons that do need to be reported. Provide the dates of and reason for the suspension, and any other information you think relevant.
By providing my e-signature below, I certify the accuracy of the information I have provided, and that I have read and agree to comply with the Vehicle Use Policy, including the driver conduct regulations.
I also understand that I have an opportunity to complete and submit this Appendix in paper format by downloading the {{http://www.wm.edu/about/administration/senioradmin/adminoffice/riskmanagement/vehiclepolicy/driverauthorizationforms/,PDF version}}, but do freely choose to submit the online version, using my Student ID# as my electronic signature.
Name:
Student ID:
IMPORTANT!
Upon submitting this form, you will be instructed to print out a copy of the Rec Sports Emergency Protocols. As an authorized driver, you must keep the Emergency Protocols in your vehicle at all times during travel to / from club activities.
By typing my initials below, I agree to print out a copy of the Rec Sports Emergency Protocols and carry them in my vehicle during travel to and from club activities.
