Waiver Form

VOLUNTEER: ADOPT-A-HIGHWAY

         INDIVIDUAL LIABILITY RELEASE FOR COMMUNITY SERVICE ACTIVITIES SPONSOR: ________________________________________________________ I, ________________________________________ hereby release the County of Benton, its employees, agents, and representatives, from any claim for damages or personal injury to myself or damage to any property owned by me as a result of my performing community services activities on projects owned or controlled by the County of Benton.

Dated this _________ Day of ______________________, 20___. ______________________________________

Signature ______________________________________ Address ______________________________________

City, State, Zip

If a minor, signature of parent or guardian is required: ______________________________________
Parent or Guardian Signature ______________________________________
Address ______________________________________City, State, Zip
Release witnessed by: ______________________________________
Signature ______________________________________ Title ______________________________________ Date