MIT – DAPER DRIVER SAFETY FORM – S2 University Safety

MASSACHUSETTS INSTITUTE OF TECHNOLOGY

DAPER Driver Certification

ALL INFORMATION PROVIDED IS CONFIDENTIAL
The DAPER Driver Safety Form must be completed by all personnel designated to drive any vehicle (leased or rented) on any official DAPER business involving the transportation of students. This form information will be kept in a file in the Office of the Associate Athletic Director for Sports Administration and will be valid for one year only.
You must receive approval for use of personal vehicles to transport students.

"*" indicates required fields

ALL INFORMATION SHOULD BE LISTED AS IT APPEARS ON YOUR DRIVERS LICENSE:

Sports

Gender

Mens

Womens

Coded

DRIVING INFORMATION

Name*

First Middle Last

Address*

Street Address City State ZIP Code

Driver's License Number*

State

Driver's License Expiration Date*

Date of Birth

MIT Email

Coach Must have or Create an Address after

Phone

Are you a Student Driver?

Are you hoding International Driving License?

AN INTERNATIONAL DRIVERS LICENSE IS NOT ACCEPTABLE FOR STUDENTS DRIVING ON MIT SPONSORED OR MIT AUTHORIZED TRIPS.

Hidden

Upload FRONT & BACK side of Your Driver's License

Drop files here or

Accepted file types: jpg, gif, png, Max. file size: 10 MB, Max. files: 2.

DRIVING HISTORY

DESCRIPTION OF PASSENGER VAN DRIVING HISTORY:

Approximate miles driven last year:

12 PASSENGER VAN

CARGO VAN:

PICK UP TRUCK:

TOTAL MILES

Have you ever been convicted of or pleaded no contest to an Operating Under the Influence of Alcohol or Drugs (OUI) violation, or an at fault vehicular accident during the past 3 years?

Yes

Details of Conviction:

Date

City & State

Description

Has your License ever been Revoked or Suspended?

Yes

Revoked or Suspended Detail

PLEASE READ THE FOLLOWING AND INITIAL TO INDICATE ACCEPTANCE*

I Accept/agree and acknowledge the following:

1. I acknowledge that I must take, complete, and pass the online driver safety course in order to be approved to drive a 12 passenger van for MIT related business.
2. I acknowledge that being fatigued while driving can be the cause of serious accidents and injuries to myself and others, and pledge not to overextend my time behind the wheel.
3. I agree not to exceed any posted speed limits.
4. I acknowledge the dangers of driving under the influence of drugs (including alcohol) and agree not to engage in such behavior.
5. I agree not to tolerate the use of illegal drugs or alcohol in any vehicle that I am driving.
6. I will require all passengers riding in any vehicle that I am driving to wear seat belts.
7. I acknowledge that safety is more important than arrival at a contest or return to MIT. I will stop if weather or other emergency conditions prohibit safe travel.
8. I agree not to drive overloaded vehicles (i.e., no more than 10 passengers in a passenger van, no more than 7 passengers in a minivan and no more than 5 passengers in a car).
9. In addition to the above, I acknowledge the personal responsibility of transporting MIT students and will not endanger their safety by taking any risks while driving.
10. I agree not to drive or rent 15 passenger vans for MIT business.
11. I agree to self-report any motor vehicle violations that I am cited for while driving, to the appropriate DAPER contact, as soon as I receive notice of a violation.
12. I agree that I will not drive a vehicle for more than five hours straight, nor more than ten hours altogether, within a 24-hour period.
13. I agree that when driving on long drives, of more than five hours’ duration, or altogether in any given day, I will not drive alone.
14. I agree that I will be held accountable for any violation of this Acknowledgment Form and/or MIT policies while driving a vehicle for MIT-related activities or events.

Signature*

I agree to list at least one additional driver on the automobile rental agreement, if applicable. I certify the accuracy of all information provided. I understand that false statements or misleading omissions may prohibit my driving of an official M.I.T. Athletic Department vehicle.