ADOPT

ADOPT-A-STREET PROGRAM

WAIVER and RELEASE FORM

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:

GROUP SIGN-OFF TO BE COMPLETED EACH TIME THE STREET IS CLEANED

ORGANIZATION_________________________________________________________________

STREET LOCATION_______________________________________________________________

NAME (Please Print):

______________________________________ _______________________________________

______________________________________ ________________________________________

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