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Utility Box Art Program <br />RELEASE FROM LIABILITY <br />Personal Information (Please print) <br />Full Name: <br />of Santa <br />Address: ?.V� Z 4�:-h, feAea F 54- <br />City: I�Cnn l-rA A, (k State: PR Zip: qZ-7 d 6 <br />Emergency Contact: JV �0 -6 7 D 3 <br />Social Security/Individual Tax Payer ID (ITIN) #: � W 20 57S5 <br />Waiver and Liability Release <br />1 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 />f;vvt (initial) I have watched and understand the instructional and safety video for <br />painting my artwork on the city-owne utility box assigned to me, <br />located on tM_Qtin 4 ibiv,onq 56^ _wrner ) a <br />Title of artwork: V ,VO <br />Si6fiature 2-2Printed Name <br />11� <br />Date <br />