Adopt-A-Street Program             

Release, Assumption of Risk and Waiver of Liability

Participant must return this signed agreement to the address below

PRIOR to their involvement in a clean-up activity.

The undersigned, being the age of 18 or above (or having authorization from a parent or adult guardian), desires to participate in the Adopt-A-Street cleanup program. I understand that I should not participate in a cleanup program unless I am physically and medically able, which I represent myself to be. I assume any and all risks associated with participation in the Adopt-A-Street program, including but not limited to, falls, collisions, the effects of weather, physical exertion, all such risks being known and appreciated by me. I attest that I am sufficiently mentally, emotionally, and physically fit to participate in the cleanup program and that my participation is entirely voluntary on my part.

The undersigned understands that his/her participation in the Adopt-A-Street program is not covered by the City of Springfield provided medical insurance.

Knowing the risks, and in consideration of being permitted to participate in the Adopt-A-Street program, I, for myself and my personal representatives, heirs and assigns, do hereby hold harmless and release, waive, discharge and covenant not to sue the City of Springfield, its officers or employees from any and all claims to liability on account of death or injury to person or property of the undersigned of any kind or nature whatsoever arising out of, or in any way connected with, the undersigned’s participation in the Adopt-A-Street program, even though the claim or liability may arise out of a condition of the premises or the past or future negligence or carelessness on the part of the City of Springfield, its officials, agents and employees or any third person, whether foreseen or unforeseen, known or unknown.

The undersigned hereby expressly agrees that this release and waiver is intended to be as broad and inclusive as permitted by the laws of the state of Missouri and that if any portion hereof is held invalid, it is agreed that the balance, not withstanding, continue in full legal force and effect.

Date:__________________                         Signature:__________________________________________

Printed Name:______________________________________

Return to: Traffic Engineering - Adopt-A-Street, PO Box 8368, Springfield, MO 65801

Phone: (417)864-1980, Fax: (417)864-1983, E-mail: adoptastreet@ci.springfield.mo.us