City of Wentzville Mission: Clean Stream
Hold Harmless and Photo Release
Sign in to Google to save your progress. Learn more
Each adult needs to accept the electronic agreement below. Legal dependants of the adult(s) can also be included on this form.
This agreement entered into on the day on date specified below by participants named below of the county of St. Charles, City of Wentzville and the State of Missouri agrees to defend, indemnify, and hold harmless the City of Wentzville, Greenway Network, Dierbergs Wentzville, LLC, Dierbergs Markets, Inc., all Dierbergs affiliates, Mission: Clean Stream sponsors and coordinating organizations, all cleanup site property owners, its agents, servants and employees from and against any and all claims of any nature whatsoever for damages, including damages or loss to personal property, personal injuries and death resulting from, in connection with, because of, or in any way related to the organizations resulting from the volunteer litter cleanup.  I also authorize any photos or videos taken of myself, and/or the participant(s), to be used in any publicity or promotional materials.
AMERICAN DISABILITIES ACT: Any participant requiring special assistance should inform appropriate staff before the cleanup.Thank you for your participation!
*
Required
Safety Video
All participants, including family members under 18 years of age, must watch this video in order to participate. Your safety is very important to us. To watch the video outside of the waiver search "Greenway Network Safety Video" in YouTube or copy this link: https://www.youtube.com/watch?v=HpD5w5JEmKo&t=4s
*
Required
Participant Name (List additional family members under 18 years of age of which you are a legal guardian  if applicable) *
Adult Participant #2 (if applicable) Additional adult participants will need to fill out another electronic form.
Adult Participant #2 Name (if applicable)
Today's Date *
MM
/
DD
/
YYYY
Group Leader Name (this person is designated as the supply pickup contact) *
Email *
Emergency Contact Name and Phone Number *
Submit
Clear form
Never submit passwords through Google Forms.
This form was created inside of City of Wentzville. Report Abuse