CITY OF LAWRENCE

SAFE WINTER WALKWAYS PROGRAM

I, the undersigned, being a volunteer involved in the City of Lawrence Safe Winter Walkways Program (hereinafter “the Program”), or being the parent or legal guardian of such a volunteer in the Program, in consideration for my or another’s participation in the Program hereby, for myself and any volunteer for whom I am a parent or legal guardian, release, discharge, and hold harmless the City of Lawrence and the Douglas County Senior Services, Inc., and their officers and employees from any and all actions, causes of action, claims or any liabilities whatsoever, known or unknown, now existing or which may arise in the future on account of or in any way related to or arising out of my participation in the Program.

I further state that I am aware of and understand the inherent risks, hazards and dangers associated with removing snow from sidewalks, including threats to life and limb, such as the possibility of slipping and falling on snow or ice, being exposed to harsh weather conditions (cold temperatures and precipitation), and perhaps experiencing complications associated with the weather conditions and physical exertion (fainting, collapse, exhaustion or other more serious complications).  I understand that these are examples of the risks, hazards and dangers associated with removing snow from sidewalks but not necessarily a complete list.

I further state that my physical health (if I am the volunteer) or the physical health of any volunteer for whom I am a parent or legal guardian, is now and will be during the volunteer’s participation in the Program, sufficiently sound to permit such person(s) to safely participate in this Program.

I further state that I understand that volunteers for all purposes, including workers compensation, are not employees of the Safe Winter Walkways Program, the City of Lawrence, or the Douglas County Senior Services, Inc.  Finally, I understand that the Program, the City of Lawrence, and the Douglas County Senior Services, Inc., are not responsible for injury or death to myself or any volunteer for whom I am a parent or legal guardian which may occur while acting as a volunteer.

            Participant’s Age:

Participant’s Name (please print)

Participant’s Signature                                         Signature of Participant’s Parent

                                                                                      or Legal Guardian (if under 18)

Date: