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Adopt-A-Street Release and Waiver of Liability

PLEASE READ CAREFULLY

THIS IS A LEGAL DOCUMENT THAT AFFECTS YOUR LEGAL RIGHTS

This Release and Waiver of Liability (the “Release”) is executed on the 4th day of November, 2023, by I, (the “Volunteer”), in favor of the City of Mission, Kansas, it's governing body, officers, employees, and agents and other volunteers (collectively, the “City”).

I, the Volunteer, desire to work as a volunteer for the City and engage in the activities related to being a volunteer ("Activities"). I

understand that the Activities may include but are not limited to the following: (description of activities)

Bending over to pick up trash, moderate lifting, using tools. and other related activities next to city/state roads.

I, the Volunteer, hereby freely, voluntarily and without duress execute this Release under the following terms:

Release and Waiver. I, the Volunteer, do hereby release and forever discharge and hold harmless the City and their successors and

assigns from any and all liability, claims and demands which I or my heirs, assigns, next of kin or legal representatives may have or

which may hereinafter accrue with respect to any bodily injury, personal injury, illness, death or property damage which arise or may

hereafter arise from or is in any way related to my Activities with the City, whether caused wholly or in part by the simple negligence,

fault or other misconduct, other than intentional or grossly negligent conduct, of the City or of other volunteers.

I understand and acknowledge that by this Release I knowingly assume the risk of injury, harm and loss associated with the Activities.

I also understand that the City does not assume any responsibility for or obligation to provide financial assistance or other assistance,

including but not limited to medical, health or disability insurance in the event of injury, illness, death or property damage.

Medical Treatment. I, the Volunteer, do hereby release and forever discharge the City from any claim or action whatsoever which

arises or may hereafter arise on account of any first aid, treatment or service rendered in connection with my Activities with the City.

If the Volunteer is less than 18 years of age, the Volunteer and the parents having legal custody and/or the legal guardians of the

Volunteer (the “Guardians”) also hereby release and forever discharge the City from any claim whatsoever which arises or may

hereafter arise on account of the decision by any representative or agent of the City to exercise the power to consent to medical or

dental treatment as such power may be granted and authorized in a Parental Authorization for Treatment of a Minor Child.

Assumption of the Risk. I, the Volunteer, understand that my Activities may include work that may be hazardous to me, including,

but not limited to, the following: physical activity; exposure to weather travel to and from the work sites; and exposure to

environmental conditions which may cause injury or worsen certain illnesses, and I accept full responsibility for providing and/or

wearing protective clothing and or safety devices as may be required. I hereby expressly and specifically assume the risk of injury or

harm in the Activities and release the City from all liability for any loss, cost, expense, injury, illness, death or property damage

resulting directly or indirectly from the Activities.

Insurance. I, the Volunteer, understand that, except as otherwise agreed to by the City in writing, the City is under no obligation to

provide, carry or maintain health, medical, travel, disability or other insurance coverage for any Volunteer. Each Volunteer is expected

and encouraged to obtain his or her own health, medical, travel, disability or other insurance coverage.

Photographic Release. I, the Volunteer, do hereby grant and convey unto the City all right, title, and interest in any and all

photographs and video or audio recordings of or including my image or voice, made by the City during my Activities with the City,

including, but not limited to, the right to use such photographs or recordings for any purpose and to any royalties, proceeds or other

benefits derived from them.

Other. I, the Volunteer, expressly agree that this Release is intended to be as broad and inclusive as permitted by the laws of the state

where the Activities take place. I further agree that in the event any clause or provision of this Release shall be held to be invalid by

any court of competent jurisdiction, the invalidity of such clause or provision shall not otherwise affect the remaining clauses or

provisions of this Release, which shall continue to be enforceable. Further, a waiver of a right under this Release does not prevent the

exercise of any other right.

First Participant's Name

First Name*

Middle Name

Last Name*

Phone*
First Participant's Date of Birth*
First Participant's Signature*
Second Participant's Name

First Name*

Middle Name

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

First Name*

Middle Name

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

First Name*

Middle Name

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

First Name*

Middle Name

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

First Name*

Middle Name

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

First Name*

Middle Name

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

First Name*

Middle Name

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

First Name*

Middle Name

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

First Name*

Middle Name

Last Name*
Tenth Participant's Date of Birth*
Parent or Guardian's Email Address

Email*

Confirm Email*
Check to receive information, news, and discounts by e-mail.
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*

Middle Name

Last Name*

Phone*
Parent or Guardian's Date of Birth*
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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