Applicant Group's Name


Contact Person


Street Address


City


Zip Code


Day Phone


E-mail


Alternate Contact Person


Street Address


City


Zip Code


Day Phone


E-mail


Adopted Road Name


General description of road to be Adopted:

From


To


Anticipated frequency of cleaning with required minimum of SIX MONTHS:

Weekly


Bi-Weekly


Monthly


Bi-Monthly


Anticipated number of participants at any cleanup?


PARTICIPANT WAIVER:

WAIVER AND RELEASE OF ALL CLAIMS AND ASSUMPTION OF RISK FOR LEE COUNTY ADOPT-A-ROAD PROGRAM/ACTIVITIES PLEASE READ THIS FORM CAREFULLY and be aware that in signing up and participating in Lee County Adopt-A-Road program/activities, you will be expressly assuming the risk and legal liability and waiving and releasing all claims for injuries, damages or loss which you or your minor child/ward might sustain as a result of participating in any and all activities connected with and associated with Lee County Adopt-A-Road program/activities. I recognize and acknowledge that there may be certain risks involved in participating in the Adopt-A-Road program/activities, and I voluntarily agree to assume the full risk of any injuries, damages or loss, that my minor child/ward or I may sustain as a result of said participation. I further agree to waive and relinquish all claims I or my minor child/ward may have (or accrue to me or my child/ward) as a result of participating in such program/activity against the County, including their respective officials, officers, employees, and volunteers (hereinafter collectively referred as “Parties”). I do hereby fully release and forever discharge the Parties from any and all claims for injuries, damages, or loss that my minor child/ward or I may have or which may accrue to me or my minor child/ward and arising out of, connected with, or in any way associated with these program/activities.

I indemnify and hold harmless Lee County, any of its employees and/or agents from any and all claims from my use of county property or participation in any county programs. I will further indemnify and “hold harmless” the County, its employees and/or agents from all costs, expenses and liabilities resulting from any claim brought from my child’s/ children’s use of county property and/or participation in county programs to the extent of the County’s liability under general law.

This is to certify that I, as parent/guardian with legal responsibility for this participant, do consent and agree to his/her release as provided above and, for myself, my heirs, assigns, and my minor child(ren)’s) involvement or participation in the program as provided above.