Liability Waiver

This form must be completed, signed and submitted prior to participating in the program. Please share this form with all of your participants to complete using the provided QR code.
QR Code for sharing Liability Waiver

Anyone who submits a form should be aware that in accordance with the North Carolina Public Records law, found in North Carolina General Statutes Chapter 132, their e-mail address is considered public record.

Event Type (Check what applies):*

Event hosted by the City of Greensboro (Volunteer events, Green Girls, Creek Week, etc.)Scheduled Adopt-a-Stream CleanupOne-time event hosted by an individual or group (Clean-a-Creek/Drain Marker Event)Required Community Service (Court ordered, School, etc.)Mitchell Water Treatment Plant TourTownsend Water Treatment Plant TourTZ Osborne Water Reclamation Facility Tour

Event Date:*

Date

Organization Name: *

Event Name/Location:*

Are you filling out this waiver for yourself (adult participant) and/or your child(ren)? Select all that apply.*

MyselfMy Child(ren)

Adult Participant/Parent/Guardian Name*

First NameLast Name

Contact Email*

example@example.com

Contact Cell Phone*

Please enter a valid phone number.

Emergency Contact Details*

Is the event City-hosted?

Adds value of 'yes' if "Events hosted by the City of Greensboro" or any of the plants are selected for the Event Type field.

Will an adult be participating?

Adds value of 'yes' if anything other than "My Child(ren)" is selected.

Emergency Contact Name*

First NameLast Name

Emergency Contact Relation*

Emergency Contact Cell Phone*

Please enter a valid phone number.

Child Participant Name(s)

Does anyone in your party have any allergies?*

YesNo

Allergy Details*

Is an epinephrine pen used?*

YesNo

Does anyone in your party have asthma?*

YesNo

Asthma Details*

Is an inhaler used?*

YesNo

Waiver of Liability / Certificate of Participation

I, {name}, understand that participating in the program or event listed below involves risk of injury. These risks may include effects of inclement weather, accidents, contacts with or actions of other participants, or slips/trips/falls, among others. I choose for myself and/or for my child(ren) to participate in the program despite the risks. By signing below, I acknowledge all risks, and I assume all responsibility of injury, illness or death in any way connected to the program. I acknowledge that I am not covered by any City of Greensboro insurance policy. In return for the opportunity to participate in the program, I agree for myself and/or my child(ren) and for my heirs, assigns, executors, and administrators to release, acquit, waive, and forever discharge any legal rights I may have to seek payment or relief of any kind from the City of Greensboro, its officers, employees, agents, or its volunteers for injury, illness, death, or property loss resulting from participation in the program.

I also agree not to sue the City of Greensboro, its officers, employees, agents, or its volunteers and to indemnify and save harmless the City of Greensboro, its officers, employees, agents, or its volunteers against all claims, actions, lawsuits and demands, including reasonable attorney fees, made by anyone for any damages, losses or injuries of any kind, including environmental, which may result from participation in the program. Permission is given for any emergency medical treatment which might become necessary, and I agree to be responsible for the expense of medical treatment or service.

If I am registering one or more children for the program or event, I agree that I am a parent, legal guardian, or am otherwise responsible for each child, and that I release waive, and discharge any legal rights that I may request on behalf of the child participant(s).

Image Release: I hereby consent to allow the exclusive use of, and relinquish all rights to, photographs, recordings, and reproductions in any manner of the likeness, voice, and/or activities of the participant and further authorize the City of Greensboro, its agents or assigns, to make unlimited use of such reproductions, including but not limited to print and/or electronically, broadcasting of the reproduction over radio, television, or on the internet with or without a name for any lawful purpose. I acknowledge that no compensation will be provided for such use by the City. I understand this release shall remain in effect unless a subsequent written notification is provided by the City. I understand that the City of Greensboro assumes no responsibility for my participation in this program.

I understand that the City of Greensboro assumes no responsibility for my participation in this program.

Signature of Participant or Parent/Guardian*

Date*

Date

Are all volunteer participants 10 years old or older?*

YesNo

**Townsend and Mitchell Water Treatment Plant is currently under construction and tours are currently suspended.**

Are all Water Plant Tour participants in the 3rd grade old or older?*

YesNo

Are all Water Reclamation Tour participants in the 6th grade old or older?*

YesNo

All Volunteers must be 10 years or older to participate in Water Resources Volunteer Events.

Anyone under 10 years of age will not be able to participate in this event. Please check the City Calendar for other upcoming events.

All Volunteers must be in the 3rd grade or older to participate in Water Supply Tours and Water Resources Programs.

Anyone below the 3rd grade will not be able to participate in this event. Please check the City Calendar for other upcoming events.

All Volunteers must be in the 6th grade or older to participate in Water Reclamation Tours.

Anyone below 6th grade will not be able to participate in this event. Please check the City Calendar for other upcoming events.

Adopt-a-Program Type:

Adopt-a-ParkAdopt-a-StreamAdopt-a-StreetAdopt-a-Trail