Community Clean Up Volunteer & Liability Waiver
Completing this form signs you up for the event and serves as a Release and Acknowledgement of Risk and Approval of Photo Publication. If participant is under the age of 18, this document must be signed by their legal guardian. Please note that a parent or guardian must accompany all under-18-participants to the event for the entirety of the program and are responsible for transportation. This form must be completed once for each event participant. 

If you have any questions or need further assistance, please contact Outreach Coordinator Jacob Diljak at 269-633-9052 or email Outreach@VanBurenCD.org.
Email *
Participant's First Name *
Participant's Last Name *
Participant is: *
Parent/Guardian First Name (if applicable):
Parent/Guardian First Name (if applicable):
Parent/Guardian Last Name (if applicable):
Parent/Guardian Email Address (if applicable)
Parent/Guardian Phone Number (if applicable):
Emergency Contact's First Name:
 *
Emergency Contact's Last Name:
 *
Emergency Contact's Phone Number:
 *
Emergency Contact's Relationship to Participant
 *
Assumption of Risk: I certify that I am the participant or the parent or guardian of the participant and that I agree to hold harmless and release from liability the Van Buren Conservation District,  or any employee for any action, claim, or damage that may arise as a result of my and my child's participation. My signature below affirms that I have read and understood the above document and that I voluntarily, freely, without duress agree to its terms (Sign name and date):
 *
Photo Publications: I hereby grant the Van Buren Conservation District to use any photo of the participant and the parent/guardian in attendance at and during any program, project and/or event, in any and all  of its publications, including website entries, brochures, press releases, Facebook posts, and other social media without payment or any other consideration. My signature below affirms that I have read and understood the above document and that I voluntarily, freely, without duress agree to its terms (Sign name and date):      
If you do not consent to photos used in this way, put in "No Photos"
 *
Which event are you registering for? *
Prześlij
Wyczyść formularz
Nigdy nie podawaj w Formularzach Google swoich haseł.
Ten formularz został utworzony w domenie Van Buren Conservation District. Zgłoś nadużycie
Formularze Google