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Thank you in advance for being part of the team that keeps our Valley, streams, and rivers clean! We couldn’t do it without our fantastic, dedicated volunteers.

CLEAN VALLEY COUNCIL WAIVER

Updated January 2023

I understand that working in or near waterways (streams, creeks, rivers) and public roadways is physically demanding which may result in injury due to falls, cuts, bites, over exertion, weather conditions, scratches, etc. If you are pregnant or think you may be pregnant, you may want to discuss this activity with your physician before participating in this program.

I affirm that I have the health, physical ability and necessary skills required to participate in this activity. I have no knowledge of any condition which could endanger me or other participants. I agree to assume all risks involved in participation in this activity, including those that are not foreseeable.

COVID-19 Safety during Cleanup activity

COVID-19 is an illness that can spread from person to person. Virginians are encouraged to follow these instructions to prevent disease spreading to people in your community.

  • Stay up to date on vaccination, including recommended booster doses.
  • Avoid contact with people who have suspected or confirmed COVID-19.
  • Follow recommendations for isolation if you have suspected or confirmed COVID-19.
  • Follow the recommendations for what to do if you are exposed to someone with COVID-19.
  • If you are at high risk of getting very sick, talk with a healthcare provider about additional prevention actions.
  • Wear Gloves
  • Wash your hands often with soap and warm water for at least 20 seconds at the end of the cleanup.
  • Use hand sanitizer until you get to running water.

I understand and agree to follow the COVID-19 guidelines to be a part of this cleanup activity. If diagnosed with COVID-19 within 14 days of the activity, it is important that you notify your cleanup partner and CVC by phone: 540-345-5523 or email: info@cleanvalley.org

I hereby release and discharge Roanoke County, City of Roanoke, Botetourt County, Town of Vinton, City of Salem and Clean Valley Council, their agents, employees, officers, successors and assigns, from all claims, demands, actions, judgments and executions which the undersigned ever had, or now has , or may have, for all personal injuries, known or unknown, and injuries to property, real or personal, caused by or arising out of the above described activity which may result from causes beyond the control of, and without the fault or negligence of Roanoke County, City of Roanoke, Botetourt County, Town of Vinton, City of Salem, Clean Valley Council, their agents, employees, officers, successors and assigns.

 



First Participant's Name

First Name*

Last Name*

Phone*
First Participant's Date of Birth*
I certify that I am 18 years of age or older
First Participant's Signature*
Second Participant's Name

First Name*

Last Name*
Second Participant's Date of Birth*
Third Participant's Name

First Name*

Last Name*
Third Participant's Date of Birth*
Fourth Participant's Name

First Name*

Last Name*
Fourth Participant's Date of Birth*
Fifth Participant's Name

First Name*

Last Name*
Fifth Participant's Date of Birth*
Sixth Participant's Name

First Name*

Last Name*
Sixth Participant's Date of Birth*
Seventh Participant's Name

First Name*

Last Name*
Seventh Participant's Date of Birth*
Eighth Participant's Name

First Name*

Last Name*
Eighth Participant's Date of Birth*
Ninth Participant's Name

First Name*

Last Name*
Ninth Participant's Date of Birth*
Tenth Participant's Name

First Name*

Last Name*
Tenth Participant's Date of Birth*
Address
Address Line 1:*
Street address, P.O. box, company name, c/o
Address Line 2:
Apartment, suite, unit, building, floor, etc.
Country:*
City:*
State/Province:*
Zip/Postal:*
Parent or Guardian's Email Address

Email
cvcnews@cleanvalley.org
A signed copy of this waiver will be sent to the email address you provide.
Emergency Contact

First Name*

Last Name*

Emergency Contact's Phone Number*

Emergency Contact's Relation to Participant
Photograph, Video & Social Media Release
As a CVC volunteer or event participant I hereby give full right and permission to Clean Valley Council only to take, record, use, and publish photograph(s)/video(s) of or including my participation in a CVC event without restriction, and use my likeness and voice in photograph(s), video, or film; and to others granted permission by CVC to use my likeness, in photograph(s), video, or film and release. My consent is freely given and I acquit, hold harmless, and forever discharge CVC, its employees, board members, affiliates, agents or contractors, successors and assigns granted permission by Clean Valley Council from any and all claims, actions, damages, causes of action and liabilities (including, without limitation, defamation or invasion of privacy), of any kind or nature, arising out of any use of my name, likeness and/or voice for advertising, publicity, trade or any other lawful purpose, in any medium, now known or hereafter to be developed.*
Agreed
Disagree
Parent(s) or court-appointed legal guardian(s) must sign for any participating minor (those under 18 years of age) and agree that they and the minor are subject to all the terms of this document, as set forth above.


By signing below the parent or court-appointed legal guardian agrees that they are also subject to all the terms of this document, as set forth above.
Parent or Guardian's Name

First Name*

Last Name*

Phone*
Parent or Guardian's Date of Birth*
I certify that I am 18 years of age or older
Parent or Guardian's Signature*
Electronic Signature Consent*
By checking here, you are consenting to the use of your electronic signature in lieu of an original signature on paper. You have the right to request that you sign a paper copy instead. By checking here, you are waiving that right. After consent, you may, upon written request to us, obtain a paper copy of an electronic record. No fee will be charged for such copy and no special hardware or software is required to view it. Your agreement to use an electronic signature with us for any documents will continue until such time as you notify us in writing that you no longer wish to use an electronic signature. There is no penalty for withdrawing your consent. You should always make sure that we have a current email address in order to contact you regarding any changes, if necessary.


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