2014-10-10NAME: Brian Matzen
ADDRESS: 1815 Grant Street CITY: Blair STATE: Nebraska
In consideration of being permitted to utilize special recreation equipment on Friday,
October 24, 2014 from 11:00 a.m. to 9:00 p.m. at the Depot located in Lions Park, 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.
-�
Printed Name:
Phone: (402) 953 -6690
r
Authorization by City: Date: