WAIVER AND RELEASE OF ALL CLAIMS FOR ADOPT-A-MEDIAN VOLUNTEER PROGRAM AND AGREEMENT TO ABIDE BY PROGRAM RULES
I have read this form (the “Waiver and Release Form”) carefully and am aware that, by signing this form and participating in the City of Madison’s Adopt-A-Median Program (the “Program”), I am Waiving and Releasing all claims arising out of such participation and agreeing to abide by the Program rules set forth herein. In consideration of the City accepting me as a volunteer participating in the Program, I hereby agree as follows:
Acknowledgment and Assumption of Risk of Injury and Loss
I have fully informed myself of all of the details of the Program and have received satisfactory answers to all questions I have concerning the Program and the risks inherent in the Program and believe and represent that I have the necessary abilities, skills and knowledge to participate in the Program. I recognize and acknowledge that the Program involves risks, including but not limited to bodily injury, death, and property loss. I hereby agree to, and do, assume the full risks of any injuries, including death, and of any property loss, and of all expenses, costs, damages and losses that I, or the person on whose behalf I am signing, may sustain as a result of participating in any and all activities connected with or associated with the Program.
I also understand I am solely and fully responsible for my actions. Furthermore, while engaged in such activities I will make safety my primary concern and at all times use and implement proper procedures and precautionary measures.
I understand that my involvement in this activity is entirely voluntary and I freely choose to participate. I agree to conduct myself in a safe and appropriate manner, at all times. I acknowledge that the City of Madison does not provide any kind of medical coverage for me, should I be injured or killed as a result of participation in this Program.
Waiver of and Release of Claims
I HEREBY AGREE TO, AND DO, WAIVE, RELEASE AND RELINQUISH ALL CLAIMS, DEMANDS, RIGHTS OF ACTION, DAMAGES, LIABILITIES AND CONTROVERSIES OF EVERY KIND, KNOWN AND UNKNOWN, PRESENT AND FUTURE, THAT I, OR THE PERSON ON WHOSE BEHALF I AM SIGNING, MAY HAVE AGAINST THE CITY AND ITS OFFICERS, AGENTS, EMPLOYEES, AND OFFICIALS ARISING OUT OF, CONNECTED WITH, OR IN ANY WAY RELATED TO THE PROGRAM OR MY PARTICIPATION THEREIN.
While participating in this volunteer activity, the City of Madison will provide the same protection to authorized volunteers for claims arising from acts done within the scope of the volunteer’s responsibilities as is provided for City employees under its liability policy.
Rules of Participation in the Program
I agree to abide by the following rules and conditions of participation in the Program:
- All participants in the Group’s Program activities must complete a signed waiver and release form. Individuals who fail to complete a signed waiver and release are not authorized to volunteer in Program activities.
- All work in the median shall be restricted from one hour after sunrise to one hour before sunset. No work shall be performed under conditions of restricted visibility or hazardous road conditions (i.e., fog, rain, snow).
- All participants shall be at least 16 years of age.
- Where individuals 18 years old or younger are working, the Group shall supply one supervisor for every 5 workers. This supervisor must be at least 21 years of age.
- All Group participants in Program activity shall properly wear safety apparel (i.e., safety vests, gloves) while working along its adopted median.
- I will not subcontract or assign my duties or responsibilities to any other person, group or organization without prior approval by the City.
- I shall obey and abide by all laws and regulations relating to safety and any other terms and conditions as required by Federal, State or local jurisdictions and report to a Group supervisor, Group Coordinator, City representative or other responsible party when I observe any violation of such laws or regulations.
- Prior to participating in the Program I agree to review the Wisconsin Department of Transportation safety training video at http://www.dot.wisconsin.gov/localgov/aid/adopt-a-highway.htm .
- During Program maintenance operations, the Group shall place traffic cones and traffic control signs supplied by the City consistent with the directives of City staff.
- I shall make sure that the Group maintains a first-aid kit and an adequate supply of drinking water while Group participants are working along an adopted median.
- All participants in Group Program activity shall be prohibited from possessing, consuming, or being under the influence of alcohol or drugs while on an adopted median, and I shall notify a Group supervisor, Group Coordinator, City representative or other responsible party when I observe any violation of this requirement.
- Safety vests, traffic control signs, and traffic cones can be obtained from the City during regular business hours (Monday-Friday, 7:30 a.m. -3:30 p.m.) by emailing firstname.lastname@example.org to set up a time for pickup.
- All materials, including safety vests, traffic control signs and traffic cones furnished by the City, shall be returned to the City upon termination of the agreement. The cost of any materials not returned by the Group to the City shall be the responsibility of the Group.
I have read and fully understand the above Waiver and Release Form and execute it of my own free will and without any reservation whatsoever.