ADOPT-A-STREET
VOLUNTEER RELEASE AND HOLD
HARMLESS
City of Mukilteo 11930 Cyrus Way Mukilteo, WA 98275 (425) 263-8000 mukilteowa.gov
The City of Mukilteo Adopt-a-Street program is for volunteers who donate their time to help keep the City of
Mukilteo clean. Participants are advised that working adjacent to a street can be hazardous. Participants
shall exercise proper care in performing litter collection activities. Participants must wear the safety hat, vest
and gloves furnished by the City of Mukilteo and must wear appropriate protective clothing such as long
pants, a long sleeve shirt and thick-soled boots or shoes.
Participants may be entitled to receive coverage for medical treatment required for injury incurred during
participation in the Adopt-a-Street program under the medical aid provisions of the Worker’s Compensation
Act, which is administered by the Department of Labor and Industries, but not for loss of time because of
injury or illness, or for lasting disability or death.
As a volunteer for the City of Mukilteo I agree to follow all of the rules outlined in the Adopt-a-Street Program
Guidelines. I acknowledge that City of Mukilteo personnel will provide direction and limited supervision
regarding my duties as a volunteer. I will use all provided equipment appropriately and follow all safety
practices.
I am aware that the work contemplated in the Adopt-a-Street program involves certain risks of physical
injury and death. I will not use any powered tools unless I have first been trained in their proper and safe
use. Being fully informed as to these risks and in consideration of being given the privilege to participate in
the Adopt-a-Street program, I hereby, on behalf of myself and my heirs, assume all risks in connection with
my participation in this program and I further hold harmless the City of Mukilteo, its officials, employees,
volunteers and agents for any injury or damages which may occur to me while I am participating in this
program and I waive any right to bring claim or lawsuit against them for any such injury, damage or death.
Furthermore, I agree to hold harmless, defend and indemnify the City of Mukilteo, its officials, employees
and agents from any and all claims and lawsuits for injury, loss, or damage to other persons or entities which
may arise in the future as a result of or in connection with my participation in the Adopt-a-Street program
except for injuries or damages caused by the sole negligence of the City of Mukilteo. I authorize any
necessary emergency medical treatment that might be required for me in the event of physical injury and/or
accident to me while participating in this program.
Printed Name of Participant: Organization:
Signature of Participant: Date:
If participant is older than 15 but less than 18 years old:
I certify that I am the parent or legal guardian of the below-named minor participant; that I have read and
understood the foregoing release and waiver; and that I, in consideration of allowing the participant to
participate in the City of Mukilteo Adopt-a-Street program, join in the release and waiver without reservation
and agree to release and waive any claim or legal cause of action that I might have arising out of any
personal injury, damage or death of the participant as against the City of Mukilteo, its officials, employees
and agents. I further grant my full consent and authorization for the named minor participant to engage in
the activity described above. Furthermore, I authorize all reasonable medical treatment that may be
necessitated in the event of injury or accident occurring to the minor participant while working in the Adopt-a-
Street program. I understand that minors under the age of 15 will not be allowed to participate.
_________________________ _______________________________
Printed Name of Parent/Legal Guardian Printed Name of Minor Participant
_________________________ _______________________________
Signature of Legal Guardian Date
click to sign
signature
click to edit
click to sign
signature
click to edit
Chrome Web Store
It looks like you haven't installed the Fill Chrome Extension Add to Chrome