Form Center

3. 

6. VOLUNTEER RELEASE, WAIVER OF LIABILITY, ASSUMPTION OF RISK, AND PHOTO RELEASE

8. Bluffdale City Volunteer Policy
   Please read before signing

10. In consideration of myself or my child being permitted to participate in any way in the above-named Volunteer Program, I, the undersigned for myself and/or my minor child do hereby: 

    1. Acknowledge that this volunteer service carries with it the potential for injury or damage, and certify as to my fitness, or my child’s fitness, that we are able to participate and that I declare that neither I, nor my child, have been advised otherwise by a qualified medical professional. 
    2. Acknowledge, agree and represent that I and my child will, at all times, be aware of the surroundings during the volunteering service and agree that I and my child considering anything related to this activity to be unsafe, will immediately advise the activity to a city supervisor and, if necessary, will leave the area immediately. 
    3. Waive, release and discharge, and covenant not to sue, the City, its elected and appointed officials, employees, volunteers, sponsors, and agents, including others who give recommendations, directions, or instructions as part of this volunteer service, from any and all liability to releasors, for any and all loss or damage, and any claim or demands therefor, on account of injury to the person, or property or resulting in my death or that of my child arising out of or related to the volunteer service, including traveling to or from the volunteer service. 
    4. Agree to indemnify, defend, and hold harmless the City and each of them from any loss, liability, damage, or cost that they may incur arising out of or related to me and/or my child's participation in this volunteer service. 
    5. Assume full responsibility for any risk of bodily injury, including illness, death, or property damage arising out of or related to the volunteer service. I agree to comply with all applicable safety rules, including wearing appropriate clothing, shoes, safety goggles, gloves, and vests while performing my volunteer activities. 
    6. Agree that this Release, Waiver of Liability, Assumption of Risk Agreement, and Photo Release extends to all acts of negligence by the City, not including gross negligence or willful misconduct, and is intended to be as broad and inclusive as is permitted by law including any governmental immunity afforded the City by law and that if any portion thereof is held invalid, it is agreed that the balance shall, notwithstanding, continue in full legal force and effect. 
    7. Authorize any medical treatment, including the administration of anesthesia, deemed advisable by any licensed physician to relieve any injuries received or illness contracted by me and/or my minor child as a participant in this volunteer service. I hereby agree to pay all costs of any medical treatment or emergency transportation. 
    8. Authorize and consent to the City, its sponsors, and any news media, and their successors and assigns and those acting under their authority, to take, publish, use in any media, and copyright photographs, videotape or other and audio or visual media, including broadcast in any media, of me and/or my minor child and agree that such may be used for any lawful purpose without further compensation or approval. 

    By signing below, I affirmatively represent that I have read this Release, Waiver of Liability, Assumption of Risk Agreement, and Photo Release.  I fully understand its terms, I understand that I have given up substantial rights by signing it, and I sign it voluntarily without assurance or guarantee being made to me and intend my signature to be a complete and unconditional release of all liability to the fullest extent permitted by law, including all acts of negligence by the City as stated above.

    I have also read the City’s volunteer policy (Bluffdale City Code Chapter 5.10 et seq.) and agree to abide by its terms.

12. Volunteer Program
    -- Select One --Bluffdale Old West Days®Bluffdale Arts Advisory BoardOther
13. If choose other, please explain
15. Volunteer First & Last Name
16. First & Last Name of Parent/Guardian
18. Address
20. City
21. State
22. Zip Code
24. Email Address
25. Phone Number
27. Electronic Signature Agreement

    By checking the "I agree" box below, you agree and acknowledge that 1) your application will not be signed in the sense of a traditional paper document, 2) by signing in this alternate manner, you authorize your electronic signature to be valid and binding upon you to the same force and effect as a handwritten signature, and 3) you may still be required to provide a traditional signature at a later date.

    1. I agree.
29. Electronic Signature
30. Date
    Date

32. Governmental entities must obtain and process only the minimum amount of personal data reasonably necessary to efficiently achieve a specified purpose, retained for required period. Utah Code § 63A-19-401(2)(c)

Leave This Blank:


34. 1. Receive an email copy of this form.
35. Email address

    This field is not part of the form submission.

36. Submit

* indicates a required field