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Utility Box Art RELEASE FROM LIABILITY Personal Information (Please print) Full Name: vi t9 ' 0 { a w r e `i Address: ` i 3 15 0 1\i- City: J4kA+Vy A -,A`-, State: CA Zip: 9 %7 O 1 Emergency Contact: L v= h C ctrc, e, 7 6 U- S U try Social Security/individual Tax Payer ID ([TIN) #: _ �3 7 �- " 77 0914 Waiver and Liability Release I have read and understand the Artists Agreement and will adhere to the rules and regulations set forth wherein and act Ina respectful manner while representing the City of Santa Ana. 1 assume the responsibility of mental and physical fitness to participate in the assignment, and agree to abide by all rules and requirements of the program. I also understand that failure to abide by the above may lead to my termination from the program. I understand that I am not considered an employee of the City of Santa Ana for purposes of Workers' Compensation, but that the City provides volunteer accident insurance in excess of any other medical Insurance I may have. I agree to comply with the City's policy regarding any injuries I incur while under the City's supervision. I agree to hold harmless the City of Santa Ana, its officers, employees and volunteers from and against any and all liability arising out of or in any way connected with my participation in the program. This release shall apply even though liability may arise out of negligence or carelessness on the part of those discharged Including their employees, agents and volunteers. This waiver and liability release shall apply to myself, as well as any of my heirs, executors or administrators. I am of lawful age and legally competent to sign this agreement. I understand the terms and have signed this document as my own free act. I have fully Informed myself of the contents of this release by reading it before I signed it. I realize that by signing this document I am giving up legal rights to which I may be entitled. „„_„_ (initial) I have watched and understand the instructional and safety video for 1 my artwork on the city -owned utility box assigned to me, on +9:w�sr '}' Q ri54.1 p artwork: N,.i-•> A^, { r&& t�;,rrt •: nt, © ITV q�'Q Sig —atur --I - Printed Name Date