City of Colorado Springs
Adopt-A-Waterway Program
Volunteer Acknowledgment
of Risk and Release
Level 1
It’s up to each of us to keep our waters clean…
*Families with children under the age of 8, please see back
Name (please print): ____________________________________________________
Mailing Address (please print): ________________________________________________________________
City (please print): _________________________________ State: ____________ Zip: __________________
Contact Information:
Home (Check One)>
Work (Check One)>
□ Phone □ Mobile
□ Phone □ Mobile
Number: _____________________________
Number: _____________________________
E-mail address: _____________________________ Fax No.: __________________
Emergency Contact (please print): _________________________________________________________
□
□
□
□
Relationship: ____________________
Home
Work <(Check One)> Phone
Mobile _____________________
______________________________________________________________________________________________________
I, the undersigned, agree for myself or for my minor child/ward, to volunteer for the City of Colorado Springs Adopt-A-Waterway
Program, and understand and agree, for myself and for my minor child/ward, to the following:
1. I will follow instructions of my/our placement and perform my/our service to the best of my/our ability.
2. I acknowledge that there are dangers and risks incurred as a result of participating in activities connected or associated with
volunteering; and, to the extent permitted by law, I hereby release and forever discharge, on behalf of myself and my
child/ward, the City of Colorado Springs, and any landowner upon whose property any program activities should take
place (“Landowner”), their employees, volunteers, and agents from any and all liability, loss, costs, charges, obligations,
expenses, attorneys’ fees, litigation, judgments, damages, claims and demands of any kind whatsoever arising from or out of
my own and my child/ward’s participation in the City of Colorado Springs Adopt-A-Waterway Program, and knowingly
assume all risk for any injuries, damage or loss to ourselves such as, but not limited to: falling down, tripping, bumping;
back, bone, joint, head, neck, muscle or spinal injuries or strains; cuts, scrapes; choking; allergies; heat stroke, heat
exhaustion, sunburn or other injuries; and/or any damage or loss sustained to our property.
3. To the extent permitted by law, I hereby agree, on behalf of myself and my child/ward, to indemnify, defend, save, and
hold harmless the City of Colorado Springs, and any Landowner, their officers, employees, volunteers, and agents from any
and all liability, loss, costs, charges, obligations, expenses, attorneys’ fees, litigation, judgments, damages, claims, and
demands of any kind whatsoever arising from or out of my own or my child/ward’s transportation to and from and
participation in the City of Colorado Springs Adopt-A-Waterway Program.
4. In the event of any emergency, I authorize the City of Colorado Springs to secure from any licensed hospital, physician
and/or medical personnel any treatment deemed necessary for my own or my child/ward’s immediate care, including
ambulance transport. Further, I agree that I will be responsible for payment of any and all medical services rendered.
5. I act only as a civilian volunteer and do not function as an employee, agent or representative of the City of Colorado
Springs, and/or any Landowner.
6. I give permission for media coverage of myself and/or my minor child/ward to be disseminated for public relations
purposes. (CROSS OUT if you do not give this permission)
Adopt-A-Waterway Risk & Release – Document No. 4
2/15/2016
I have read and fully understand the provisions outlined in the City of Colorado Springs Adopt-A-Waterway Program risk and
release form. This acknowledgment of risk and release shall not be modified orally. All minors’ signatures must be accompanied
by the signature of the parent or guardian.
_______________________________________________
_________________________________________________
Volunteer Name (please print)
Volunteer Signature
_______________________________________________
_________________________________________________
Signature of Parent or Guardian (if volunteer is a minor)
Date
______________________________________________________________________________________________________
Parent’s Names (please print): ____________________________________________________
Children’s Names and Ages:________________________________________________________
Mailing Address (please print): ________________________________________________________________
City (please print): _________________________________ State: ____________ Zip: __________________
Contact Information:
Home (Check One)>
Work (Check One)>
□ Phone □ Mobile
□ Phone □ Mobile
Number:
_____________________________
Number:
_____________________________
E-mail address: _____________________________ Fax No.: __________________
Emergency Contact (please print): _________________________________________________________
Relationship: ____________________
□ Home □ Work
<(Check One)>
□ Phone □ Mobile
_____________________
In addition to the agreement above, all parties agree to the following amended material:
1. Children under the age of 8 may participate in program though they are advised to stay out of streams, creeks, and
drainageways at all times. The City of Colorado Springs recommends that children under the age of 8 participate
from the banks of streams, creeks, and drainageways.
2. Close adult supervision is required for children under the age of 8 at all times.
3. Educational safety checklist must be presented to ALL children under the age of 18
Checklist:
o Streams, creeks, and drainageways are not a safe place to play
o Never go into a stream, creek, or drainageway without an adult
o Be aware of potential flash flooding. Water levels can greatly increase in seconds causing flash
flooding.
o Chemicals and other materials in the water can harm you

o
Pesticides, herbicides, fertilizers, motor oil, antifreeze, pet waste, hypodermic needles,
etc.
Be aware that streams, creeks, and drainageways are natural habitats for animals.
I have read and fully understand the provisions outlined in the City of Colorado Springs Adopt-A-Waterway Program risk and
release form. This acknowledgment of risk and release shall not be modified orally. All minors’ signatures must be accompanied
by the signature of the parent or guardian.
_______________________________________________
Volunteer Name (please print)
_______________________________________________
Signature of Parent or Guardian (if volunteer is a minor)
Adopt-A-Waterway Risk & Release – Document No. 4
_________________________________________________
Volunteer Signature
_________________________________________________
Date
2/15/20162