Adopt-1-Street Supplemental Registration Form
Please Note:  Adult supervision is NOT provided by the community / city at this event.  All volunteers under the age of 18 must be accompanied by a participating adult.  Thank you.

If you have any immediate questions, contact us at (818) 519-7567 or jillmather@earthlink.net.

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Email *
Name of Group that you are representing: *
Full Name (must be over the age of 18 to register) *
Date of Birth: *
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Will a participant under the age of 18 be accompanying you?   *
Please list the names and ages of all minor participants: *
Mailing Address: *
Phone Number: *
The Important Stuff
Please Note:  Adult supervision is NOT provided by the community / city at this event.  All volunteers under the age of 18 must be accompanied by a participating adult.  Thank you.
1, the undersigned, being of lawful age or the parent or legal guardian of the volunteer involved in the Adopt-1-Street litter pick up effort, in consideration of being allowed to participate in this effort, hereby agree as follows:
I, personally and on behalf of my heirs, personal representatives, executors and assigns, and on behalf of the minor and the minor’s heirs, personal representatives, executors and assign, hereby release, waive, discharge, and covenant not to sue the City, its City Council, and City departments or subdivisions, its employees, representatives, others, agents, volunteers, and successors and assigns, (hereinafter collectively referred to as “Releasees”), from any and all claims, demands, actions, causes of action, judgments, costs, expenses, attorneys’ fees or other damage or liability, on account of, or in any way related to, or arising out of my participation, or the minor’s participation, in the Adopt-1-Street litter pick-up event. *
I, personally or on behalf of the minor, agree to defend at my expense, pay on behalf of, indemnify and hold harmless, Releasees from and against any and all claims, demands, liens, liabilities, judgments, losses and damages including, but not limited to, costs, expenses and attorneys fees, for damage to property or bodily or personal injuries, including death resultingtherefrom, sustained by any person or persons, which damage or injuries are alleged or claimed to have arisen out of or in connection with, in whole or in pa!, directly or indirectly, my participation, or the minor’s participation, in the Adopt-1-Street litter pick-up event. *
I, personally or on behalf of the minor, agree to assume liability for any non-participants who accompany me or the minor during the Adopt-1-Street litter pick-up event. * *
I, personally or on behalf of the minor, hereby give the City, its employees, representatives, officers, agents, volunteers, and successors and assigns, permission to take and use interviews, photographs, or videotapes of myself and/or the minor for promotional and educational purposes. This publicity may include publication of the photographs in publications, posters, brochures and newsletters, on the City’s website, radio station, or cable television channel, or other forms of publicity for the City. I understand there is no monetary compensation for the use of these photographs. *
CLEAN-UP EVENT SAFTY SHEETStay safe while doing your part to make the city a more beautiful place to live, work and play.  Follow these important safety tips at all times:
I, the undersigned, being of lawful age or the parent or legal guardian of the volunteer involved in the Adopt-1-Street litter pickup effort, have read the above paragraphs and the attached safety sheet, full understand, and voluntarily sign this Agreement and agree to be bound by its terms.:
Full Name Signature
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