Douglas County Forms

2. Volunteer Group
4. First Name of Participant (Child)*
5. Last Name of Participant (Child)*
7. Address*
9. City*
10. State*
11. Zip Code*
13. Phone Number*

15. WARNING! PLEASE READ CAREFULLY Participants are advised that working adjacent to any road is a DANGEROUS ACTIVITY. Risks associated with this activity include, but are not limited to, serious injury or death. Each participant is further advised that the risk of harm is present even if all safety precautions are followed. Each participant is advised by the Volunteer Group about safety rules and regulations while performing this activity, and agrees to exercise due care and caution at all times while performing litter clean-up and other program activities. The Volunteer Group has provided safety training using materials and training aids furnished by the County. The training took place before participation in program activities. Participants have been advised that they are required to wear the hard hat and safety vest furnished by the County. In addition, participants are required to wear the appropriate protective clothing during program activities. A list of requirements is included in the packet provided to the Volunteer Group. PARTICIPANTS ARE ADVISED THAT THE SAFETY PRECAUTIONS DESCRIBED ABOVE DO NOT GUARANTEE THEIR SAFETY WHILE A PARTICIPANT IS IN THIS PROGRAM.

17. LIABILITY RELEASE AND PROMISE NOT TO SUE—PLEASE READ CAREFULLY By signing below, I certify that: I am the legal parent or guardian of the above named child and give my permission for the child to participate in the Adopt-A-Road Program. I fully understand the risks associated with the activity and agree to review the safety information with my child. I recognize and understand that participation in the Adopt-A-Road Program is voluntary and involves risks and inherent dangers that may cause injury and/or death. I have read the information provided and understand the responsibilities and risks associated with the program. Therefore, I agree to hold harmless and release Douglas County, its agents, employees and officials from liability for all damages, including injury and death, resulting from participation in this program, except for liability deemed to be the County’s sole negligence.

19. I have read, understood, and accepted the conditions of the Liability Release printed above:

21. 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.
23. Electronic Signature*
25. First Name (Parent/Guardian)*
26. Last Name (Parent/Guardian)*
28. Phone Number (Parent/Guardian)*

30. In the event a parent or guardian is not available, please provide the name and phone number of an alternate contact.

32. Emergency Contact Name*
33. Phone Number*
Leave This Blank:


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

    This field is not part of the form submission.

37. Submit

* indicates a required field