2013-09-05ADDRESS: Black Elk Neihardt Park
In consideration of being permitted to access the Tower of the Four Winds on
from ` p.m. to a , p. m. at the Black
Elk Neihardt Park located in Blair, Nebraska, 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:
Printed Nan
Phone: `U ,�' — L a 2 - 2 �a
Date: � 5 /
Authorization by City. Date.
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