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Utility Box Art Pilot Project <br />Personal Information (Please print) <br />RELEASE FROM LIABILITY <br />Full Name: KR STY M UIZG-71\R0 <br />Address: 1,07 NJ HASTjNVS SJ <br />City: <br />S Arf\fTA 1�� A <br />Emergency Contact: (11H ) H g 3 - C I S �l <br />Social Security No.: � D 3 - u Li ,�) b 0-7 <br />Waiver and Liability Release <br />State: C A Zip: 'T2-703 <br />Ana <br />I have read and understand the Artists Agreement and will adhere to the rules and regulations <br />set forth wherein and act in a respectful manner while representing the City of Santa Ana. I <br />assume the responsibility of mental and physical fitness to participate in the assignment, and <br />agree to abide by all rules and requirements of the program. I also understand that failure to <br />abide by the above 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 <br />any other medical insurance I may have. I agree to comply with the City's policy regarding any <br />injuries 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 <br />carelessness 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 <br />have 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. <br />realize that by signing this document I am giving up legal rights to which I may be entitled. <br />Signature Printed Name <br />2 /ZOIC�1 <br />Date <br />