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Required fields are marked with an asterisk (*).
If using a mobile device, please click the blank space below the questions to view the drop-down options and make your selection.
Do you have any access requirements or accommodation requests you'd like us to be aware of?
Please feel free to list any accommodations or allergies below.
Birthdate *
A valid date as MM/DD/YYYY (for example: 11/30/2015)
First Name *
Last Name *
Volunteer Leader First Name *
Volunteer Leader Last Name *
Cell Phone *
For example, 123-456-7890
Address *
City *
State *
Zip Code *
Group/Organization (If applicable):
If you are a new leader, please enter what you'd like your sign to say below.
Please note, signs will not be ordered until you complete at least one clean up and schedule a second unless communicated otherwise.
Adoption Signage Wording (up to 2 lines, max. 15 characters/line) *
Backup Contact Name:
Backup Contact Email:
Backup Contact Phone:
Are you 18 years or older? *
Parent/Legal Guardian Full Name *
Parent/Legal Guardian Cell Phone *
Emergency Contact Full Name *
Emergency Contact Cell Phone *
Preferred Adoption Start Date (you will still be required to renew at the start of the calendar year): *
A valid date as MM/DD/YYYY (for example: 11/30/2015)
Estimated Number of Participants
Proposed Work Schedule - Minimum Requirement is Quarterly Cleanups (Once Every 3 Months)
Would you allow other volunteers to assist with your adoption area? (you may select both options.)
Have you fully read and understood that this program requires at least a yearly requirement where cleans up must be done quarterly?
Do you accept and agree to the Adopt-a-Park and Trail Agreement listed in the description above? *
Do you accept and agree to the attached Permission to Participate, Release and Waiver of Liability, Assumption of Risk and Indemnity Agreement and Photo Release? *
Waiver
In consideration of me, or my minor child, being permitted to participate in any way in the above-named Volunteer Program, I, the Undersigned, for myself and my minor child, all of my or my minor child's, personal representatives, executors, administrators, heirs, next of kin, successors and assigns, herein referred to as "Releasors", do hereby:
1. Acknowledge that this volunteer service carries with it the potential for serious injury, death and/or property damage, and certify as to my physical fitness and that of my minor child to participate and declare that neither I, nor my minor child, have been advised otherwise by a qualified medical professional.
2. Acknowledge, agree, and represent that I and my minor child will, at all times, be aware of the surroundings during the volunteer service and agree that if I or my minor child consider anything related to this Activity to be unsafe, will immediately advise the Activity officials of such, and if necessary, will leave the area or refuse to participate further in the volunteer service.
3. Waive, release and discharge, and covenant not to sue, the City of Des Moines, Iowa, its elected and appointed officials, employees, volunteers, sponsors, partner organizations and agents, including others who give recommendations, directions, or instructions as part of this volunteer service, hereinafter referred to in this document as "City", from any and all liability to Releasors, except for my minor child, for any and all loss or damage, and any claim or demands therefore, on account of injury to the person or property, or resulting in my death or that of my minor child, including but not limited to illness or damage to me or my minor child’s property arising out of or related to the volunteer service, including traveling to or from the volunteer service and before, during, and after the volunteer service.
4. Agree to Indemnify and Save and Hold Harmless the City and each of them from any loss, liability, damage, or cost to third parties that they may incur arising out of or related to me or my minor child’s participation in this volunteer service.
5. Assume full responsibility for any risk of bodily injury, including but not limited to illness, death or property damage arising out of or related to the volunteer service. I agree to comply with all applicable safety rules, including wearing protective clothing, close-toed shoes/boots, safety goggles, gloves, and vest while performing my volunteer activities.
6. Agree that this Permission to Participate, Release and Waiver of Liability, Assumption of Risk, and Indemnity Agreement and Photo Release extends to all acts of negligence by the City, but excluding willful, wanton or reckless conduct, and is intended to be as broad and inclusive as is permitted by law including any governmental immunity afforded the City by law and that if any portion thereof is held invalid, it is agreed that the balance shall, notwithstanding, continue in full legal force and effect.
7. Authorize any medical treatment, including the administration of anesthesia, deemed advisable by any licensed physician and/or Emergency Responder (EMT) to relieve any injuries received or illness contracted by me or my minor child as a participant in this volunteer service. I hereby agree to pay all costs of any medical treatment or emergency transportation.
8. Authorize and consent to the City, its sponsors, and any news media, and their successors and assigns and those acting under their authority, to take, publish, use for public display in any media now or hereinafter known and including without limitation on the City’s social media accounts, and copyright photographs, videotape or other audio or visual media, including broadcast in any media, of me or my minor child, including but not limited to those that capture me or my minor child’s name, voice, and/or image, and agree that such may be used for any lawful purpose without limitation or reservation and without further compensation or approval.
I have read the Permission to Participate, Release and Waiver, Assumption of Risk and Indemnity Agreement and Photo Release, fully understand its terms, understand that I have given up substantial rights of my own and of my minor child by signing it, and sign it voluntarily without assurance or guarantee being made to me and intend my signature to be a complete and unconditional release of all liability to the fullest extent permitted by law, including all acts of negligence by the City as stated above. I agree that this Permission to Participate, Release and Waiver, Assumption of Risk and Indemnity Agreement and Photo Release will be IN EFFECT for 5 YEARS from the date of my signature and/or electronic submission, unless otherwise terminated by me in writing delivered to the City.
In consideration of me, or my minor child, being permitted to participate in any way in the above-named Volunteer Program, I, the Undersigned, for myself and my minor child, all of my or my minor child's, personal representatives, executors, administrators, heirs, next of kin, successors and assigns, herein referred to as "Releasors", do hereby:
1. Acknowledge that this volunteer service carries with it the potential for serious injury, death and/or property damage, and certify as to my physical fitness and that of my minor child to participate and declare that neither I, nor my minor child, have been advised otherwise by a qualified medical professional.
2. Acknowledge, agree, and represent that I and my minor child will, at all times, be aware of the surroundings during the volunteer service and agree that if I or my minor child consider anything related to this Activity to be unsafe, will immediately advise the Activity officials of such, and if necessary, will leave the area or refuse to participate further in the volunteer service.
3. Waive, release and discharge, and covenant not to sue, the City of Des Moines, Iowa, its elected and appointed officials, employees, volunteers, sponsors, partner organizations and agents, including others who give recommendations, directions, or instructions as part of this volunteer service, hereinafter referred to in this document as "City", from any and all liability to Releasors, except for my minor child, for any and all loss or damage, and any claim or demands therefore, on account of injury to the person or property, or resulting in my death or that of my minor child, including but not limited to illness or damage to me or my minor child’s property arising out of or related to the volunteer service, including traveling to or from the volunteer service and before, during, and after the volunteer service.
4. Agree to Indemnify and Save and Hold Harmless the City and each of them from any loss, liability, damage, or cost to third parties that they may incur arising out of or related to me or my minor child’s participation in this volunteer service.
5. Assume full responsibility for any risk of bodily injury, including but not limited to illness, death or property damage arising out of or related to the volunteer service. I agree to comply with all applicable safety rules, including wearing protective clothing, close-toed shoes/boots, safety goggles, gloves, and vest while performing my volunteer activities.
6. Agree that this Permission to Participate, Release and Waiver of Liability, Assumption of Risk, and Indemnity Agreement and Photo Release extends to all acts of negligence by the City, but excluding willful, wanton or reckless conduct, and is intended to be as broad and inclusive as is permitted by law including any governmental immunity afforded the City by law and that if any portion thereof is held invalid, it is agreed that the balance shall, notwithstanding, continue in full legal force and effect.
7. Authorize any medical treatment, including the administration of anesthesia, deemed advisable by any licensed physician and/or Emergency Responder (EMT) to relieve any injuries received or illness contracted by me or my minor child as a participant in this volunteer service. I hereby agree to pay all costs of any medical treatment or emergency transportation.
8. Authorize and consent to the City, its sponsors, and any news media, and their successors and assigns and those acting under their authority, to take, publish, use for public display in any media now or hereinafter known and including without limitation on the City’s social media accounts, and copyright photographs, videotape or other audio or visual media, including broadcast in any media, of me or my minor child, including but not limited to those that capture me or my minor child’s name, voice, and/or image, and agree that such may be used for any lawful purpose without limitation or reservation and without further compensation or approval.
I have read the Permission to Participate, Release and Waiver, Assumption of Risk and Indemnity Agreement and Photo Release, fully understand its terms, understand that I have given up substantial rights of my own and of my minor child by signing it, and sign it voluntarily without assurance or guarantee being made to me and intend my signature to be a complete and unconditional release of all liability to the fullest extent permitted by law, including all acts of negligence by the City as stated above. I agree that this Permission to Participate, Release and Waiver, Assumption of Risk and Indemnity Agreement and Photo Release will be IN EFFECT for 5 YEARS from the date of my signature and/or electronic submission, unless otherwise terminated by me in writing delivered to the City.
Check here to show you accept the terms stated above for yourself.
I, the Undersigned, for myself and/or my minor child, have read the Permission to Participate, Release and Waiver, Assumption of Risk and Indemnity Agreement and Photo Release, fully understand its terms, understand that I have given up substantial rights of my own and of my minor child by signing it, and sign it voluntarily without assurance or guarantee being made to me and intend my signature to be a complete and unconditional release of all liability to the fullest extent permitted by law, including all acts of negligence by the City as stated above. I agree that this Permission to Participate, Release and Waiver, Assumption of Risk and Indemnity Agreement and Photo Release will be IN EFFECT for 5 YEARS from the date of my signature and/or electronic submission, unless otherwise terminated by me in writing delivered to the City.
In consideration of me, or my minor child, being permitted to participate in any way in the above-named Volunteer Program, I, the Undersigned, for myself and my minor child, all of my or my minor child's, personal representatives, executors, administrators, heirs, next of kin, successors and assigns, herein referred to as "Releasors", do hereby:
1. Acknowledge that this volunteer service carries with it the potential for serious injury, death and/or property damage, and certify as to my physical fitness and that of my minor child to participate and declare that neither I, nor my minor child, have been advised otherwise by a qualified medical professional.
2. Acknowledge, agree, and represent that I and my minor child will, at all times, be aware of the surroundings during the volunteer service and agree that if I or my minor child consider anything related to this Activity to be unsafe, will immediately advise the Activity officials of such, and if necessary, will leave the area or refuse to participate further in the volunteer service.
3. Waive, release and discharge, and covenant not to sue, the City of Des Moines, Iowa, its elected and appointed officials, employees, volunteers, sponsors, partner organizations and agents, including others who give recommendations, directions, or instructions as part of this volunteer service, hereinafter referred to in this document as "City", from any and all liability to Releasors, except for my minor child, for any and all loss or damage, and any claim or demands therefore, on account of injury to the person or property, or resulting in my death or that of my minor child, including but not limited to illness or damage to me or my minor child’s property arising out of or related to the volunteer service, including traveling to or from the volunteer service and before, during, and after the volunteer service.
4. Agree to Indemnify and Save and Hold Harmless the City and each of them from any loss, liability, damage, or cost to third parties that they may incur arising out of or related to me or my minor child’s participation in this volunteer service.
5. Assume full responsibility for any risk of bodily injury, including but not limited to illness, death or property damage arising out of or related to the volunteer service. I agree to comply with all applicable safety rules, including wearing protective clothing, close-toed shoes/boots, safety goggles, gloves, and vest while performing my volunteer activities.
6. Agree that this Permission to Participate, Release and Waiver of Liability, Assumption of Risk, and Indemnity Agreement and Photo Release extends to all acts of negligence by the City, but excluding willful, wanton or reckless conduct, and is intended to be as broad and inclusive as is permitted by law including any governmental immunity afforded the City by law and that if any portion thereof is held invalid, it is agreed that the balance shall, notwithstanding, continue in full legal force and effect.
7. Authorize any medical treatment, including the administration of anesthesia, deemed advisable by any licensed physician and/or Emergency Responder (EMT) to relieve any injuries received or illness contracted by me or my minor child as a participant in this volunteer service. I hereby agree to pay all costs of any medical treatment or emergency transportation.
8. Authorize and consent to the City, its sponsors, and any news media, and their successors and assigns and those acting under their authority, to take, publish, use for public display in any media now or hereinafter known and including without limitation on the City’s social media accounts, and copyright photographs, videotape or other audio or visual media, including broadcast in any media, of me or my minor child, including but not limited to those that capture me or my minor child’s name, voice, and/or image, and agree that such may be used for any lawful purpose without limitation or reservation and without further compensation or approval.
I have read the Permission to Participate, Release and Waiver, Assumption of Risk and Indemnity Agreement and Photo Release, fully understand its terms, understand that I have given up substantial rights of my own and of my minor child by signing it, and sign it voluntarily without assurance or guarantee being made to me and intend my signature to be a complete and unconditional release of all liability to the fullest extent permitted by law, including all acts of negligence by the City as stated above. I agree that this Permission to Participate, Release and Waiver, Assumption of Risk and Indemnity Agreement and Photo Release will be IN EFFECT for 5 YEARS from the date of my signature and/or electronic submission, unless otherwise terminated by me in writing delivered to the City.
Check here to show you accept the terms stated above for yourself or for a minor child that you are the parent/legal guardian for.
I, the Undersigned, for myself and/or my minor child, have read the Permission to Participate, Release and Waiver, Assumption of Risk and Indemnity Agreement and Photo Release, fully understand its terms, understand that I have given up substantial rights of my own and of my minor child by signing it, and sign it voluntarily without assurance or guarantee being made to me and intend my signature to be a complete and unconditional release of all liability to the fullest extent permitted by law, including all acts of negligence by the City as stated above. I agree that this Permission to Participate, Release and Waiver, Assumption of Risk and Indemnity Agreement and Photo Release will be IN EFFECT for 5 YEARS from the date of my signature and/or electronic submission, unless otherwise terminated by me in writing delivered to the City.
