2012-05-19 Boy Scouts of America at Lions ParkCITY OF BLAIR
PROPERTY ACCESS
WAIVER OF LIABILITY
NAME:
It) 14 'Oa � l �P� �se�r- (fir' ✓e o� ��i�Sc�,{�6
ADDRESS: (D fl H71 tCiY'(r'fb►' CITY: Blair STATE: Nebraska
In consideration of being permitted to utilize special recreation equipment on Saturday,
May 19, 2012 from 12:00 Noon to 4:00 p.m. at the Lions Park located in Blair,
Nebraska, special recreation equipment being further described as a "Bounce House ",
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.
Signature: Date:
Printed Name: J 0 1) i (A&
Contact Phone: (402) ?- ( d ((
S -/o -�a
Authorization by Y *�Cjlt? Cit : Date:
BOY SCOUTS OF AMERICA®
MID - AMERICA COUNCIL
i
Janine Hunt
Goldenrod District Executive
0:402.278.1016
611 Hillcrest Dr.
F:402.431.0444 Blair, NE 68008
www.mac - bsa.org janine.hunt @scouting.org
1k