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Full Name: t <br />Address: Q <br />City:_) <br />Util <br />Box Art Program <br />RELEASE FROM LIABILITY <br />Personal Information (Please print) <br />�Qr /oS(DO eve�(4o <br />Emergency Contact: <br />V\ <br />of Santa <br />)y ifG11 <br />p---_ <br />0 ?P A— 2,— <br />Social Security/Individual Tax Payer ID (ITIN) <br />Waiver and Liability Release <br />I have read and understand the Artists Agreement and will adhere to the rules and regulations set <br />forth wherein and act in a respectful manner while representing the City of Santa Ana. I 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 Ana 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 or carelessness <br />on the part of those discharged including their employees, agents and volunteers. <br />This waiver and liability release shall apply to myself, as well as any of my 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 myself 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 />(initial) I have watched and understand the instructional and safety video for <br />my artwork on the city -own( <br />on CO r- nC, P'" i-,r V4 rn <br />Title of artwork: 0 K) I Cl H- n <br />1 Printed <br />Date <br />Te, <br />V�p o i�J, ST_\� <br />