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Clean Up Event Acknowledgement of Risk Signature Page

  1. KSSB mock up 4
  2. Town of Shady Shores

    Keep Shady Shores Beautiful

    101 S. Shady Shores Rd., Shady Shores, TX 76208

    940-498-0044 x 160

    Program Administrator:

     Katie Klein, 

    Program Department: 

    Community Relations

  3. KTB logo
  4. If part of group participating

  5. Enter the address (or event) or a description of the location you are clean up

  6. Please include City and State
  7. Certification and Acknowledgement of Risks*

    I hereby certify that all statements made in this application are true and correct to the best of my knowledge, and I authorize the investigation of all matters contained in the application or data pertinent to my volunteering. 

    I acknowledge that any false statements or misrepresentation on this application will be cause for refusal of placement or immediate dismissal. 

    I understand and agree that in the performance of voluntary services,

    I am not a Town of Shady Shores employee and shall have no rights to wages or benefits and no promise, expressed or implied of consideration for future employment. 

    I agree and to indemnify and hold the Town of Shdays shores employees and contractors harmless from any and all liability for any injury that I might incur arising out of or in any way connected to my participation in this program. 

    I also agree to grant full permission to the Town of Shady Shores to use my name and any photographs, video or recordings for any purpose whatsoever without any obligation, liability, or compensation to me. 

    Volunteers are not covered under the Town of Shady Shores Workers Compensation Plan. Therefore it is recommended volunteers have their own medical insurance coverage. If a serious incident occurred, a legal claim can be presented and an investigation into negligence will take place. For more information refer to the Town of Shady Shores. 

  8. Parent or Legal Guardian signing for a child under 18
  9. Leave This Blank:

  10. This field is not part of the form submission.