Liability Release
City of Central Point
Adopt-A-Street Program
Acknowledgement of Warning and Release
I, _____________________________, acknowledge that I have read the Adopt-A-Street Safety Guide and
that I understand the safety procedures contained in the brochure. I acknowledge that I am aware of the dangers
associated with working on a street right-of-way.
I agree to release and discharge the City of Central Point, its officers, agents, and employees liable for any claims
of any kind which may result directly, or indirectly, in connection with cleaning up the adopted area, which may
result from, or in connection with my participation in the Adopt-A-Street Program.
I further agree to indemnify and hold harmless the City of Central Point, its officers, agents, and employees from
liability for any damages or injuries (including death) resulting from any acts or failure to act on my part during the
participation in said voluntary activities on or near the street right-a-way. I acknowledge that this release form is
valid and effective for the term of this agreement and any subsequent renewals.
_____________ ____________________________
Date Signature
____________________________
Adopt-A-Street Group Name
