CLAYTON STATE UNIVERSITY

Electric Vehicle Charging Station (EVCS) Registration

AND

ASSUMPTION OF RISK AND RELEASE

User's Name: ______

Department & Office # (for Faculty and Staff) :______or

Student Identification #______

Email: ______Campus or Mobile Phone: ______

Vehicle Make/Model/ Year/Color:

______

License Plate (State & #): ______One Way Commute Distance in Miles: ______

You may e-mail the completed form to:r deliver to Public Safety.

Please initial here:

  • EVCS reserved spaces are for vehicle charging only and EVCS charging capability at CSU is a limited resource. Please do not park in EVCS charging designated spaces when you are not charging your vehicle.
  • Please limit your charging session to 4 hours maximum and do not leave your vehicle there after your charging session is complete.
  • Please configure your ChargePoint User Account and Card so that you receive email or text messages when your vehicle is fully recharged.
  • We will contact you for your feedback regarding your experience using the station.

ASSUMPTION OF RISK AND RELEASE

By signing below, the User named above hereby assumes all risk ofinjury or damage whichmight occur to me, my passengers, and myproperty and to anyone or their property dueto or resulting from myusage of the electric vehicle charging stations (EVCS). These risks include those foreseen and unforeseen, known and unknown and all events. The User releases and forever discharges Clayton State University, its employees, administrators, agents, assigns, and all other persons, firms, corporations and institutions, who it might be claimed to be liable, from any and all claims, demands, actions, causes of action or suits of any kind or nature whatsoever and particularly on account of all injuries known and unknown, both to person and property, which have resulted or may in the future develop from any accident which might occur as a result from using this electric vehicle charging station. The User hereby declares that the terms of this agreement have been completely read and are fully understood and voluntarily accepted for the purpose of making a full and final compromise adjustment and settlement of any and all claims, stipulated or otherwise, on account of the injuries and damages above mentioned, and for the express purposes of precluding forever any further or additional claims arising out of any possible accident, injury, property damage or claim by the User. This release is binding on the Users’ heirs, executors, assigns and administrators.

The User is attesting to be experienced in the proper use of the EVCS. By signing below, the User hereby acknowledges that he/she has read and understands all of the above.

Signature ofUser:______Date:______

April 2, 2015