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Public Works HomepageCITY OF KIRKSVILLE
ADOPT-A-STREET PROGRAM
WAIVER, RELEASE & INDEMNIFICATION AGREEMENT
This release acknowledges that the undersigned has requested participation in the Adopt-A-Street Program. Furthermore, the undersigned does hereby waive, release, and forever discharge the City of Kirksville, Missouri, its agents and employees, and shall hold harmless and indemnify said City of Kirksville, Missouri, its agents and employees from any and all claims, counts, causes of action and demands of every kind and nature, including reasonable attorneys fees and cost of litigation, which may arise out of, result from or in any manner pertain to any and all loss, costs, damage or expense whatsoever from my participation in the following activity, to-wit the Adopt-A-Street Program:
Organization_________________________________________________________________________
Street Section ________________________________________________________________________
WARNING – THIS IS A RELEASE. PLEASE READ BEFORE SIGNING!
Signed this____________________day of______________________,20____
_____________________________________________________________________ Sponsor Signature Print Name
_____________________________________________________________________ Address City, State Zip Code Phone#
Email Address_______________________________________________________
_____________________________________________________________________ Witness Signature Print Name
_____________________________________________________________________ Title Phone# Email Address
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