EXTENDED PARKING REQUEST

Submitting this completed request form to Parking Services allows a CSM student or employee to leave
his/her vehicle within the campus boundaries for an extended period of time. Vehicle registration and a
valid CSM parking permit must be current and visible during your absence. It may be necessary to move
your vehicle; therefore, keys must be provided to Parking Services and vehicle must be parked in Lot A.
T


This option is not available for visitors!
PERSONAL INFORMATION
Name: _________________________________________ CWID: _____________________
Emergency Contact Name:










Emergency Contact Phone Number: ______________________________________________
Registered Owner Name: ______________________________________________________
Phone: ______________________________________
Address: ____________________________________________________________________
____________________________________________________________________________
VEHICLE INFORMATION
Year: __________ Make: _______________________ Model: _______________________

Color: __________________________ Your Permit #: ______________________________

License Plate Number and State of Issue: _________________________________________

Vehicle Registration Expiration:* ________________________________________________

* Registration must be current and valid thru the expected date of return indicated below *

In consideration for being permitted to leave my vehicle at CSM for this extended period of time, I, for myself, and on behalf of my heirs,
personal representatives, and assigns, do hereby RELEASE, WAIVE, DISCHARGE, AND COVENANT NOT TO SUE the Colorado School of
Mines, and its Board of Trustees, officers, employees, agents, and representatives, from any and all liability for any and all damages, losses, or
injuries to persons or property, which arise out of, occur during, or result from leaving my vehicle on campus.
By my signature below, I acknowledge and represent that I have read this WAIVER OF LIABILITY, ASSUMPTION OF RISK AND
INDEMNIFICATION AGREEMENT, fully understand and accept its terms, and sign it voluntarily.


X








Date:




Date of Departure: ______________________
Expected Date of Return:





Keys Provided to Parking Services:

(Employee signature upon accepting keys) ___________________________________________________

Parking Services is not responsible for keys left more than 30 days beyond expected date of return!
COLORADO SCHOOL OF MINES
FACILITIES MANAGEMENT DEPT
PARKING SERVICES OFFICE

1318 MAPLE STREET
GOLDEN, CO 80401
(303) 273-3100