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2. DOUGLAS COUNTY ADOPT-A-ROAD REGISTARTION FORM
4. NAME OF PARTICIPANT *
5. Group Name or Number
7. Address*
8. City*
9. Zip Code*
11. Email Address
12. Phone Number*
14. EMERGENCY CONTACT*
16. Address
18. City
19. Zip Code
20. Phone Number*
22. WARNING! PLEASE READ CAREFULLY

    Participants in the Adopt-A-Road Program are advised that working adjacent to any road is a DANEROUS ACTIVITY. Risks associated with this activity include, but are not limited to, serious injury or death. Each participant is further advised that the risk of harm is present even if all safety precautions are followed. 

    Each participant shall exercise due care and caution at all times while performing litter pickup and other program activities. The Volunteer Group shall provide Participants with safety training using materials and training aids furnished by the County before Participants participate in any program activities. Participants shall wear a hard hat and safety vest furnished by the County and appropriate protective clothing during program activities.

    PARTICIPANTS ARE ADVISED THAT THE SAFETY PRECAUTIONS DESCRIBED ABOVE DO NOT GUARANTEE THEIR SAFETY WHILE A PARTICIPANT IN THIS PROGRAM.

    By signature below I acknowledge that I have read this form completely, and I understand the responsibilities and risks associated with participation in the Adopt-A-Road Program. I understand that participation in this program is voluntary, and I agree to accept the risks connected with this activity, and further agree to hold harmless Douglas County and its agents, employees, and officials from liability for damages, including injury or death, resulting from participation in this program, except for any liability deemed to be the County’s sole negligence.

24. Electronic Signature Agreement

    By checking the "I agree" box below, you agree and acknowledge that 1) your application will not be signed in the sense of a traditional paper document, 2) by signing in this alternate manner, you authorize your electronic signature to be valid and binding upon you to the same force and effect as a handwritten signature, and 3) you may still be required to provide a traditional signature at a later date.

    1. I agree.
26. Electronic Signature

    Signature of Participant, if age 18 or older

Leave This Blank:


28. 1. Receive an email copy of this form.
29. Email address

    This field is not part of the form submission.

30. Submit

* indicates a required field