Fillable Bastrop County Adopt-a-County Road Program Application for Participation (Texas Secretary of State)

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Bastrop County Adopt-a-County Road Program Application for Participation (Texas Secretary of State)

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Bastrop County Adopt-a-County Road Program
Application for Participation
BastropCountywillworkwiththeadoptingParticipanttodeterminethespecificsectionofCountyroadtobeadopted.
TheCountymayconsidersuchfactorsaswidthofrightofway,congestionandsightdistanceofroadwaysin determining
whatsectionsofroadshallbeeligibleforadoption.
PleasereadPage2fortheAdopt‐a‐CountyRoadProgramguidelines.
(NameofIndividualorOrganization) (DateofApplication)
(Streetaddress) (City,ZipCode)
(Mailingaddress) (City,ZipCode)
(Emailaddress) (Est.No.ofpeopleparticipatingineachCleanup)
(Nameofauthorizedrepresentative) (Authorizedrepresentative’sEmailaddress)
(Mailingaddress) (City,ZipCode)
(Dayphonenumber) (Cellphonenumber)
(Nameofalternaterepresentative) (Alternaterepresentative’sEmailaddress)
(Mailingaddress) (City,ZipCode)
(Dayphonenumber) (Cellphonenumber)
CountyRoadsectionyouareinterestedinadopting:
Pleaseprintthisdocumentandmail,fax,orcallthePrecinctforemailaddress:
CountyCommissioner(whatprecincttheroadresidesin)804PecanStreetBastrop,Texas78602
Fax:512‐581‐4005orEmail:CallthePrecincttheroadresidesinforemailaddress
ThefollowingguidelinesapplytotheBastropCountyAdopt‐a‐CountyRoadProgram
•
ParticipationintheProgramisopentoanindividual,family,communityorganization,governmentalentity,youth
organization,privatebusiness,civicandnon‐profitorganization,religiousgroup,fraternity,sororityandschool.
•
ProgramparticipantsmustagreetoholdtheCountyharmlessandagreenottoholdtheCountyresponsibleforanyinjuries
thattheymaysufferordamagestheymaycauseorsufferasaresultofparticipationintheProgram.
•
Participantcanadoptasectionofroadwaytomemorializeindividualswhohavedied.Therecognitionsignmay
include
thephrase“inmemoryof”,thenameofthepersoninwhosememorythesectionisadopted,andthenameofthe
adopting
entity.
•
OnlyBastropCountyroadsareeligibleforadoption.
TheParticipantwill:
•
Obeyandabidebyalllawsandregulationsrelatingtosafetyandsuchothertermsandconditionsasmayberequiredbythe
Countyforspecialconditionsofaparticularadoptedsection.
•
AdoptasectionofCountyroadthatisaminimumoftwo(2)miles(unlessthetotallengthoftheroadisshorterthantwo
(2)miles)foraminimumoftwo(2)years.
•
Pickuplitteraminimumoftwo(2)timesperyearormoreasneededatapproximatelyquarterlyintervalsunlessthe
CountyCommissionerdeterminesfewertimesperyearisadequate.
•
Appointanauthorizedrepresentativeandanalternaterepresentativeoftheparticipatinggroup.
•
Furnishadequatesupervisionbyone(1)ormoreadultsforminorvolunteersofaparticipatinggroupwhoare15yearsof
ageorolder,withatleastone(1)adultforeverythree(3)childrenwhoare10to14yearsofage.Childrenundertheageof
10maynotparticipateintheProgram.
•
Conductagroupsafetymeetingpriortoeachpickupday.
•
ObtainrequiredsuppliesandmaterialsfromtheCountyduringregularbusinesshours.
•
Setuptrafficcontrolsignsduringthecleanupandremoveaftercleanup.
•
WearCountyfurnishedsafetyvestsduringtrashpickup.
•
Placelitterintrashbags.PlacetrashbagsinanapprovedareaandBastropCountywillmakearrangementstodiscardatan
approveddisposalsite.
•
ReturnunusedmaterialsandsuppliestotheCountywithintwo(2)businessdaysfollowingeachcleanup.
•
Notpossessorconsumealcoholicbeveragesorillegaldrugswhileontheadoptedsection.
•
Maintainafirst‐aidkitandadequatedrinkingwaterwhilepickinguplitterontheadoptedsectionofroad.
•
AssignmentofresponsibilitiestoanyothergroupisnotallowedwithoutconsentoftheCountyCommissionerofthe
precinct.
•
HavetheoptionofrenewinganagreementsubjecttotheapprovaloftheCountyCommissioneroftheprecinct.
•
AdvisetheCommissioneroftheprecincteachtimethatlitterhasbeenpickedupontheadoptedroad.
TheCountywill:
•
WorkwiththeparticipatingindividualorgrouptodeterminethespecificsectionofCountyroadtobeadopted.
•
Erectatleasttwo(2)permanentsignsontheadoptedsectionofCountyroadwiththeparticipant’snamedisplayed.
•
Providesafetyinformation,trashbags,trafficcontrolsignsandsafetyvests.
•
Removelitterbagsfromtheadoptedsectionandwillremoveanylarge,heavyorhazardousitems.
IfintheCountyCommissioner’ssolejudgmentthattheindividualorgroupisnotmeetingthetermsandconditionsofthe
agreement,theCountymayterminatetheagreementandremovethesign(s)upon30days’notice.
CountyCommissioner’sSignature AuthorizedSignatureforGroup Date
Howtoapply:
ContacttheCountyCommissioner(whatprecincttheroadresidesin)andrequestanapplicationformorvisittheCounty’s
websitewww.co.bastrop.tx.ustoprinttheform.SubmitthecompletedformtotheCountyCommissioner(whatprecincttheroad
residesin)to804PecanStreet,BastropTX78602orcalltheCountyCommissionersofficefortheiremailaddress.
EffectiveMay13,2019
GENERALRELEASEOFLIABILITYANDWAIVEROFCLAIMS
FORBASTROPCOUNTYADOPT‐A‐COUNTYROADPROGRAM
1.InconsiderationforreceivingpermissiontoparticipateinBastropCountyAdopt‐a‐CountyRoadProgram,(the“Activity”),Ihereby,
onbehalfofmyself,myminorchildren,orminorsinmycare,COVENANTNOTTOSUEANDRELEASEBASTROPCOUNTY,itsofficers,
electedofficials,agents,servants,employees,volunteers,andotherpersonsconnectedwithorassociatedwiththe
BASTROPCOUNTY(collectivelythe“Releasees”)fromanyandallliability,claims,demands,actionsandcausesofactionwhatsoever
arisingoutoforrelatedtoanyloss,damage,orinjury,includingdeath,thatmaybesustainedbyme,oranyoftheproperty
belongingtomeorinmypossession,custody,orcontrol,WHETHERCAUSEDBYTHENEGLIGENCEOFTHERELEASEES,orotherwise,
whiletravelingtoorfromorparticipatingintheActivity,orwhilein,onoruponthepremiseswheretheActivityisbeingconducted.
2.IunderstandthattheReleaseesdonotassessorwarrantytheproficiencyoftheinstructorsandotherparticipantsintheActivity,
andtheReleaseesdonotmakeanywarrantyorrepresentationofanytype,kindorcharacter,whatsoever,astoexistingconditions
uponthelandsImayenterfortheActivity.IamparticipatingintheActivityatmyownrisk,andIacceptlandorpropertyinthe
existingconditions,andrecognizethatexerciseActivitiesareinherentlyhazardousactivitiesandexposemetodangerousconditions,
risksandhazards.

3.IagreeandrepresentthatIwillcomplywithallcurrentlawsoftheStateofTexas,allfederallaws,andanyothercontrolling
authority’srulesandregulationswhileparticipatingintheActivity,including,butnotlimitedto,lawsregardingnarcotics,alcoholand
othermatters.IagreethatIwillabstainfromtheuseofanyalcoholorillegalnarcoticswhileengagedintheActivity.

4.IamfullyawareoftherisksinvolvedandhazardsconnectedwithparticipationintheActivityandIherebyelecttovoluntarily
participateintheActivitywithfullknowledgethatsaidActivitymaybehazardoustomeandormyfamilymembers.IVOLUNTARILY
ASSUMEFULLRESPONSIBILITYFORANYRISKSOFLOSS,PROPERTYDAMAGEORPERSONALINJURY,INCLUDINGDEATH,thatmaybe
sustainedbyme,oranylossordamagetopropertyownedbymeormyfamilymembersorinourpossession,custody,orcontrol,as
aresultofbeingengagedinsuchanactivity,WHETHERCAUSEDBYTHENEGLIGENCEOFRELEASEESOROTHERWISE.
5.IfurtherherebyAGREETOINDEMNIFYANDHOLDHARMLESStheRELEASEESfromanyloss,liability,damageorcosts,including
courtcostsandattorneyfees,thattheReleaseesmayincurduetomyparticipationintheActivity,WHETHERCAUSEDBYTHESOLE
ORPARTIALNEGLIGENCEOFRELEASEESorotherwise.
6.IfurtheragreethatwhileattendingorparticipatinginthisActivitythatIwillnotsell,advertise,orsolicitanyproduct,serviceor
anyitemwhatsoeverORattempttodothesame.
7.IamsigningthisGeneralReleaseofLiabilityandWaiverofClaimstogainaccesstothisprogram,whichisconductedontheright‐
of‐wayofCountyRoadsofBastropCounty,Texas;
8.IstatethatIhaveconsultedwithmypersonalphysicianregardingwhetherthisActivityissafeformeand/ormyspouseand/or
childrenandthatIamnotrelyingonanyrepresentationfromBastropCountythatmymedicalconditionallowssuchactivities.
9.IunderstandthattheReleaseesmaynotmaintainanyinsurancepolicycoveringanycircumstancearisingfrommyparticipationin
theActivity.Assuch,IamawarethatIshouldreviewmypersonalinsurancecoverage.
10.ItismyexpressintentthatthisGeneralReleaseofLiabilityandWaiverofClaimsshallbindthemembersofmyfamilyandspouse,
ifIamalive,andmyheirs,assignsandpersonalrepresentative,ifIamdeceased,andshallbedeemedasaRELEASEANDWAIVEROF
CLAIMSAGAINST,ANDACOVENANTNOTTOSUEtheabovenamedRELEASEES.IherebyfurtheragreethatthisGeneralReleaseof
LiabilityandWaiverofClaimsshallbeconstruedinaccordancewiththelawsoftheStateofTexas,andanydisputeconcerningthis
agreementwillbeheardinthefederalcourtsoftheWesternDistrictofTexasorstatecourtsinBastropCounty,Texas.
11.INSIGNINGTHISRELEASE,IACKNOWLEDGEANDREPRESENTTHATIhavereadtheforegoingGeneralReleaseofLiabilityand
WaiverofClaims,understanditandsignitvoluntarilyasmyownfreeactanddeed;nooralrepresentations,statements,or
inducements,apartfromtheforegoingwrittenagreement,havebeenmade;Iamatleasteighteen(18)yearsofageortheparent
orguardianofaminorchildandfullycompetenttoexecutethisGeneralReleaseofLiabilityandWaiverof
Claimsonmybehalforonbehalfofmychildorward;andIexecutethisGeneralReleaseofLiabilityandWaiverofClaimsforfull,
adequateandcompleteconsiderationfullyintendingtobeboundbysame.
Signedthis________dayof_________________20______
SignatureofParticipant–ParentorGuardianmustreadandsignifparticipantisunder
18yearsofage:

PrintedNameofParticipant: SignatureofParticipant

PrintedNameofParentorGuardian: SignatureofParentorGuardian

PrintedNameofSpouse(ifparticipating): SignatureofSpouse
NAMESANDDATESOFBIRTHOFMINORCHILDRENPARTICIPATING
1._____________________________________________________
2._____________________________________________________
3._____________________________________________________
4._____________________________________________________
5._____________________________________________________
6._____________________________________________________
7._____________________________________________________
8._____________________________________________________
9._____________________________________________________
10.____________________________________________________
11.____________________________________________________
12.____________________________________________________
13.____________________________________________________
14.____________________________________________________
15.____________________________________________________
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Bastrop County Adopt-a-County Road Program Application for Participation (Texas Secretary of State)

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Completed 25 January 2021

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