2017-05-08 Bounce House-Jennifer LosekeCITY OF BLAIR
PROPERTY ACCESS
WAIVER OF LIABILITY
NAME: Jennifer Loseke
ADDRESS: 1285 N. 10th St., Apt 102, Blair, Nebraska 68008
In consideration of being permitted to have a bounce house for event being held in the
park on Saturday, May 6, 2017 from 12:00 p.m. to 6:00 p.m. at Lions Park, the
undersigned assumes all risks of damage or loss either to his / her person, guests or
property from any and all causes, including but not limited to negligence, violation of
law, or willful misconduct on the part of the City of Blair, its employees or agents, during
the time the undersigned has access to the City of Blair property indicated above. It is
understood that the City of Blair, it's employees or agents, shall incur no liability or
obligation to the undersigned, his / her heirs, successors or assignees for any damages,
injury or other loss that the undersigned may have as a result of his/her gaining access
to City of Blair property. Further, the undersigned must fully comply with all safety
requirements of the City of Blair.
THIS WAIVER APPLIES TO THE DATE OR OCCURRENCE THAT THE
UNDERSIGNED HAS ACCESS TO THE CITY OF BLAIR PROPERTY.
t
Signature:
Printed Name:.. ' Jennifef Loseke
Phone: (402) 427-3822
Date: Ii
Authorization by City: ( Date: L 1
Brenda Wheeler
From:
Sarah Backman
Sent:
Wednesday, April 19, 2017 1:27 PM
To:
Brenda Wheeler
Subject:
Bounce house waiver for 5-6-2017
Hi Brenda,
Jennifer Loseke, is having a birthday party at the Lions Park Shelter on 5-6-2017 between 12-6 pm. Her phone number is
402-427-3822 and her address is 1285 N 10th St. Apt 102, Blair. I told her that we would have the form ready by so she
could sign any time between tomorrow and Friday May 51h
Thak you,
Sarah Backman
Utility Billing Clerk
City of Blair
218 South 16th Street
Blair, NE 68008
Phone: (402) 426-4191
Fax: (402) 426-4195
sbackman, blairnebraska.on,