City of Wentzville Mission: Clean Stream 2022 (round 2)

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Hold Harmless and Photo Release

Email *

Please select a preferred in April or May in which you would like to do a cleanup. *

YYYY

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 Markets, Inc. & Dierbergs Wentzville. LLC., 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), by event organizers/staff, other volunteers or myself or that is shared with the City of Wentzville may to be used in any promotional materials.

AMERICAN DISABILITIES ACT: Any participant requiring special assistance should inform appropriate staff before the cleanup.Thank you for your participation!

By checking this box I certify that I have read this document and I fully understand its content and accept the terms of this agreement to participate. I am aware that this is a release of liability for me and my dependants and a contract and I sign it of my own free will.

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

By checking this box I certify that each participant included on this hold harmless has watched this safety video above.

Required

First Adult Participant Name *

Adult Participant #1 *

By checking this box I certify that I have read this document and I fully understand its content and accept the terms of this agreement to participate. I am aware that this is a release of liability for me and my dependents and a contract and I sign it of my own free will.

Required

Second Adult Participant Name (if applicable)

Adult Participant #2 (if applicable) Additional adult participants will need to fill out another electronic form.

By checking this box I certify that I have read this document and I fully understand its content and accept the terms of this agreement to participate. I am aware that this is a release of liability for me and my dependents and a contract and I sign it of my own free will.

Please list any participating dependents here (children under 18).

A parent or legal guardian must fill out this form for their dependents. If you have children participating other than your own, please have the child's parent or legal guardian fill out this form.

Participating Dependents (if applicable)

By checking this box I certify that I have read this document and I fully understand its content and accept the terms of this agreement to participate. I am aware that this is a release of liability for me and my dependents and a contract and I sign it of my own free will.

Today's Date *

YYYY

Group Name (if applicable) *

Phone Number *

Emergency Contact Name and Phone Number *

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