Laserfiche WebLink
Utility Box Art <br />ILELENam.. .m.@.w E t».LIOM LIAG IL' 1 i <br />jPersonal Inforaation (Please print) <br />Full Name:[ G 41 _ i �_ t, `� <br />.. <br />Address,:M1��:�...��Gla�.�C�,C\�.\�t, v�9�..__,.w---...-_...--.-.-..._.�...,....,....-.--•--^�- <br />cit -- <br />ErergencY <br />Social Seourity/Individual Tax Payer ID (]TIN} #: 'j �__ . •. •-� W--� <br />Walver and Liatalilty Releaee <br />I hive read and understand the Artists Agreement and will adhere to the rules and regulations Set <br />forth wherein and art in a respectful manner while reprea®rating the City of Santa Ana. t assume <br />the responsibility of mental and physical fitness to participate in the assignment, and agree to abide <br />by all rules and requirements of the program. I also understand that failure to abide by the above <br />may lead to my termination from the program. <br />I understand that I am not considered an employee of the City of Santa Aria for purposes of <br />Workers' Compensation, but that the City provides volunteer accident insurance In excess of any <br />other medical insurance I may have. I agree to comply with the City's policy regarding any injuries I <br />incur while under the City's supervision. <br />I agree to hold harmless the City of Santa Ana, its officers, employees and volunteers from and <br />against any and all liability arising out of or in any way connected with my participation in the <br />program. This release shall apply even though liability may arise out of negligence ar carelessness <br />on the part of those discharged including their employees, agents and volunteers. <br />This waiver and liability release shrill apply to myself, as well as any of limy heirs, executors or <br />administrators. <br />I am of lawful age and legally competent to sign this agreement. I understand the terms and have <br />signed this document as my own free act, <br />I have fully informed rnyself of the contents of this release by reading it before I signed it. I realize <br />that by signing this document I am giving up legal rights to which I may be entitled. <br />;. �. t e <br />(iftitlal) l have watched and undelst�tnd the inetruotionat an sa v so <br />rating my a tar on the cl »tawrreact Itillty box nasal lied to rare, <br />fated ona of artwork: AB <br />_.... �,�=l-a�.- _.....�... <br />�T' <br />Printed Name <br />