Requesting Agency/Organization ___________________________________________________

Contact: (Person responsible for van management)
    Name _________________________________     Phone ____________________
    Address __________________________________________________________

4-H Agent Contact (if different from above)
    Name: _________________________,     County/City _____________________

Designated Driver(s): (Attach a copy of volunteer registration form and/or driver's license.)
    Name ________________________________
    Title _________________________________
    Check one: State employee ____,     Registered NRCS/4-H Volunteer ____
    License Number ________________________

    Name ________________________________
    Title _________________________________
    Check one: State employee ____,     Registered NRCS/4-H Volunteer ____
    License Number ________________________

Date(s) for Van Use:
    From (Date/Time): ________________________
    To (Date/Time): _________________________

Location for Van Use: ____________________________________________________________

Estimated Mileage: (From 4-H Center) __________________

Audience: ___________________________________

Purpose or Description of Program:
___________________________________________________________________
___________________________________________________________________
___________________________________________________________________

All Water Wizard Van users must comply with the printed regulations and procedures in this manual. All users must be familiar with the use of Water Wizard Van educational components. Please review and adhere to the following:

Water Wizard Van Regulations	Van Security and Liability
Maintenance and Expense Reimbursement	Driver Designations and Van Transport
Accident Procedures/Reporting	Awning Procedures
Equipment and Materials Checklist	Educational component use and care (refer to Program Manual)

All van users must submit Inventory, Inspection and Activity/Travel Reports when the van is returned to the 4-H Center.

I/We agree to operate the Water Wizard Van in accordance to the regulations and procedures set forth in the Operations Manual. I/We assume full responsibility for the Water Wizard Van and its contents during the period indicated above. I/We release all parties of Virginia Cooperative Extension, 4-H and the Virginia 4-H Centers from liability for accident, injury or damage incurred during activities and events related to the Water Wizard Van.

Print Name (Authorized Person): ______________________

Signature: ______________________

Date: ___________________________