Please print and sign the following waiver form before you participate in a Highland
Avenue clean up day sponsored by Pierce Downer's Heritage Alliance. Please then
send your completed waiver form to Jim Cavallo, either by faxing it to 630-971-1505
or mailing it to him at 6912 Main Street, Suite 123, Downers Grove, IL 60516.

                          ADOPT-A-HIGHWAY PROJECT WAIVER

I, _____________________________ on behalf of myself (“Adult Participant”)
(Participant Name/Legal Guardian)
or as parent/legal guardian of

________________________________ a minor child under the age of eighteen (18),
(Minor Child Participant)
agrees and understands as follows:

The aforementioned volunteer (“Participant”) desires to assist the Village of Downers
Grove (“Village”) and, if applicable, the County of DuPage (“County”) in carrying out
duties for the Village of Downers Grove Adopt-A-Highway Project(s) for calendar
year 20_____.

That Participant understands and agrees to the following conditions concerning
participation in this project:

a. That Participant’s time and services are being donated, and at no time shall
Participant be considered an employee of the Village or County or as an
independent contractor of the Village or County;

b. That Participant assumes full responsibility for their conduct and actions,
including any injury or damage that may result while assisting the Village or County;

c. That the Participant hereby agrees to indemnify, defend and hold harmless
the Village and County, their officers, agents and employees from any and all
claims, actions, suits or liability whatsoever arising out of participation in the Project;

d. Permission is granted to the Village to photograph or videotape any and all
participants of this event for the purposes of publicity, public relations, advertising,
newsletters and the like.  Participant hereby discharges and releases the Village
and County from any and all claims arising from the use of the photos, videotapes
and any likeness thereof for the above-stated purposes.

Signature: ______________________________________ Date: ________________________
(Adult Participant or Parent/ Legal Guardian of Minor Child)

Telephone Number: _______________________ Minor’s Date of Birth: ____________ (if applicable)
__________________________________________________________________________________________
In case of emergency, please provide the name and telephone number of the person or persons
we should contact:

______________________________________________

Phone: ______________________________________________

Please return the completed form to Public Works – 5101 Walnut Avenue, Downers Grove, IL 60515
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