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Utility Box Art Program <br />of Santa Ana <br />RELEASE FROM LIABILITY <br />Personal Information (Please print) <br />Full Name: Darren Edward Hostetter <br />Address: 6501 Lewis Ave. <br />City: _Long Beach —State: —CA Zip:_90805 <br />Emergency Contact: Bridget Bojorquez <br />(562)713-2273 <br />Social Security/Individual Tax Payer ID (ITIN) #: <br />568-63.3358 <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 <br />I 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 thi document as my own free act. <br />(initial) I have watched and understand the instructional and safety video for <br />plaavdrfgllgr�nknhv afkrgsAliefritgrowdedtsitifitoibcedeoniadinpet before I signed it. I realize <br />tbsbEgtGiWming this document I am giving up legal rights to which I may be entitled. <br />Title of artwork: Seifies 2 <br />Signature <br />Date <br />Darren Hostetter <br />Printed Name <br />