New Submission

How will you be engaging with the City?*

PERSONAL INFORMATION

(PLEASE PRINT, FIELDS WITH * ARE REQUIRED)

First Name*

Last Name*

Mailing Address*

Street Address

Address Line 2

City

State / Province / Region

Postal / Zip Code

Country

Primary Phone Number*

Email*

Emergency Contact Name*

Emergency Contact Relationship*

Emergency Contact Phone Number*

Department Assignment*

Advisory Body assignment

Program Area(s) Assignment:

Special Accommodations Requested:

RESPONSIBILITIES, ACKNOWLEDGEMENTS, WAIVER AND LIABILITY RELEASE

1. Always act in a respectful and professional manner

2. Be safety conscious at all times and follow all applicable safety practices and guidelines

3. Be courteous to all persons with whom I come in contact

4. Never use alcohol or controlled substances at any time

5. Always check in and out with my designated supervisor

6. Attend all scheduled assignments as a condition of participation in this volunteer program

In consideration of my participation as an affiliate of the City, I agree as follows:

I will adhere to the responsibilities listed above and all applicable City rules, policies and regulations while representing the City of San Luis Obispo. I understand that my relationship with the City as an affiliate may be terminated at any time and for any reason.

I am mentally and physically fit to participate in the position description provided to me.

I am not considered an employee of the City of San Luis Obispo for any purpose, and I am not entitled to compensation for my services as an affiliate or eligible for any City provided employee benefits. I am eligible to be reimbursed for expenses I incur to perform affiliate services for the City that have been approved in advance by my designated supervisor.

I understand that accidents and injuries can occur during my activities for the City, including when walking on uneven or natural terrain or on slippery surfaces, while riding in a City vehicle or other form of transportation, or under a variety of other conditions and circumstances. I expressly assume the risk that I may sustain injuries while providing services for the City.

I further understand that my performance of services for the City may involve exposure to other persons, including program participants, members of the public and City staff, and it is possible to contract communicable diseases, including, but not limited to, COVID-19, during the performance of services for the City. I understand and acknowledge that, while City staff and affiliates will be trained in, and implement, hygiene, sanitation, and safety measures as recommended by the Centers for Disease Control and Prevention (“CDC”) to decrease the likelihood of spreading a communicable disease such as COVID-19, the City cannot ensure or guarantee that I will not be exposed to or contract a communicable disease during my performance of services as an affiliate for the City and I expressly assume the risk of contracting a communicable disease while performing services for the City.

For any injuries I may sustain while providing services for the City, I understand and acknowledge that, as an affiliate, I am not covered by Workers’ Compensation, but the City may provide volunteer accident insurance which is supplemental to and in excess of any medical insurance I may have. I agree to comply with the City’s policy on reporting any injuries incurred while performing services for the City. Any claims are subject to the terms, conditions, and limitations provided in the City’s volunteer accident insurance policy, if provided by the City.

I hereby release, discharge and hold harmless the City of San Luis Obispo and each of its elected officials, officers, employees, agents and volunteers (“City Indemnitees”) from and against, and covenant not to sue City Indemnitees, or any of them, for, any and all claims, demands, actions, causes of action, damages or liability of any kind or nature whatsoever arising out of or in any way connected with my participation in the City's programs. THIS WAIVER AND RELEASE SHALL APPLY EVEN THOUGH LIABILITY MAY ARISE OUT OF NEGLIGENCE OR CARELESSNESS ON THE PART OF THOSE DISCHARGED INCLUDING THEIR ELECTED OFFICIALS, OFFICERS, EMPLOYEES, AGENTS AND VOLUNTEERS. For any claims of liability asserted against me or the City arising out of or in any way connected with my participation in the City's programs, subject to the terms, conditions and limitations of the applicable policy, the City may provide general liability insurance coverage for affiliates.

This waiver and liability release shall apply to myself, as well to my heirs, executors, administrators, and assigns. I understand and agree that the foregoing waiver and liability release is intended to be as broad and inclusive as is permitted by the laws of the State of California and that if any portion is held to be void, invalid or unenforceable, the remaining portions shall continue in full legal force and effect.

I am of lawful age and legally competent to sign this Registration and Waiver form and have signed this document as my own free act. I HAVE READ, UNDERSTAND AND HAVE FULLY INFORMED MYSELF OF THE CONTENTS OF THIS REGISTRATION AND WAIVER FORM BEFORE I SIGNED IT. I UNDERSTAND THAT BY SIGNING THIS DOCUMENT I AM GIVING UP LEGAL RIGHTS TO WHICH I MAY OTHERWISE BE ENTITLED.

Photo Release Consent*

I agree to allow my photograph, image, or likeness to be used in published materials and web sites involving the City’s programs. I grant the City all right, title, and interest in and to any and all photographic images, video or audio recordings and other replications or documentation of my person or voice made by the City during my participation with the City, including, but not limited to, any royalties, proceeds, or other benefits that are derived from such photographs or recordings.I DO NOT agree to the above regarding use of my photograph, image or likeness.

Signature*

Parent/Guardian Signature (if under 18 years of age)

IF AN AFFILIATE IS UNDER THE AGE OF 18, THE AFFILIATE’S PARENT (OR LEGAL GUARDIAN, IF ANY) MUST SIGN ON BEHALF OF THE AFFILIATE. I am the parent or legal guardian of the above affiliate, and s/he has my permission to participate in this activity on the terms, conditions and limitations provided in this Registration Form and Waiver. I have read and agree to the provisions stated above for myself and the minor. I consent to and allow the minor to participate in this activity without my supervision and I assume all the risks from such participation.

Date*

CITY AFFILIATE REGISTRATION AND WAIVER

RESPONSIBILITIES, ACKNOWLEDGEMENTS, WAIVER AND LIABILITY RELEASE