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4.  Newton County Bicentennial District 5 Cleanup -

   Saturday, October 16, 2021

6. Name of Group:
8. Contact Person:
10. Phone Number
12. Email Address:
14. Estimated Number of Volunteers:
16. Number of T-shirt sizes:
18. XXXL
19. XXL
20. XL
22. L
23. M
24. S

26. (Packing team will substitute sizes as necessary. Participants served on a first-registered, first-served basis.)

28. Please complete attached health survey and release forms.

    (One of each of these 3 forms is required for each person in your group.)

30. Event Type and Location:

    (Example: Roadside Cleanup at Hwy. 278)

32. Signature of Leader:

    (Signature of Parent, if under 18)

34. KNBCOMMUNITY CLEANUP-LIABILITY/RELEASE FORM

    Medical Release, Photo Release, & Liability Waiver Form

    In consideration for permission to participate in the cleanup event (including, if applicable, use of free cleanup supplies, assistance from staff, free garbage disposal, and access to the cleanup site), I agree that:

    Voluntary-My participation in this Cleanup is voluntary. I will select the activities in which I will participate. I will choose activities that are within my physical capabilities. I will stay away from water if! cannot swim and/or if! have any open cuts.

    Assumption of Risk-I realize that during this Cleanup, there are several ways that I could potentially hurt myself if! am not careful or choose a task that I am not capable of doing. For example, I might choose to (a) clean up near highways or toads, (b) clean up slippery streams and river banks, (c) cut vegetation with sharp tools, (d) pick up sharp items, and (e) be exposed to or pick up materials/plants/insects that may cause allergic reactions in some people and/or contain harmful pollutants, bacteria, or parasites. I realize that my participation in any of these activities is strictly voluntary and that I assume the risks associated with these activities. I could: (a) receive cuts and abrasions, (b) lose personal property such as watches or jewelry, and (c) suffer serious bodily injury.

    Waiver I release the sponsors, organizers) volunteers, and site property owners (as well as all of their affiliates, directors, officers, trustees, employees, representatives, or agents) from all actions or claims of any kind that relate to my participation in the Cleanup, with the exception, to the extent required by law, of willful and wanton conduct and gross negligence, I understand and acknowledge that this waiver binds my heirs, administrators, executors, personal representatives, and assigns.

    Hold Harmless-I hold the sponsors,  organizers, volunteers, and site owners harmless and indemnify them against all actions or claims (including reasonable attorneys• fees, judgments and costs) with respect to any injuries, death, or other damages or losses, resulting from my participation in the Cleanup, regardless of whether or not the act or omission is caused in part by a party indemnified hereunder.

    Medical Treatment-If I am injured during the Cleanup, the organizers or volunteers of the Cleanup may render medical services to me or request that others provide such services. By taking such action, the organizers and volunteers are not admitting any liability to provide or to continue to provide any such services and that such action is not a waiver by the organizers or volunteers of any rights under this release and waiver. Should I require transport to a medical facility as a result of an injury, I am financially responsible for such transportation and medical treatment costs. If I am injured during the Cleanup, it is my responsibility to seek appropriate medical care and to notify the Cleanup organizers. I understand that this waiver will have no bearing on any workers’  compensation claims that I may make as a result of my participation in this event.

    Pictures‑I agree that any pictures or videos taken of me or my children/dependents during the cleanup can be used by Keep Newton Beautiful for publicity and/or future promotional campaigns.

    I UNDERSTAND AND AGREE WITH THE CONTENTS OF THIS DOCUMENT. ANY QUESTIONS I MAY HAVE HAD ABOUT THIS DOCUMENT WERE ANSWERED TO MY SATISFACTION.

36. Participant's Printed Name:
37. Parent's Printed Name (if participant is under 18):
39. Signature/Date:
40. Parent's Signature/Date:
42. Address:
43. Email:
45. Emergency Contact Person:
46. Emergency Contact Person's Phone Number:

48. Prescreening Health Survey - to be conducted prior to registration and repeated 24 hours prior to event

    People with COVID-19 have had a wide range of symptoms reported - from mild symptoms to severe illness1. Symptoms may appear two to 14 days after exposure to the virus.

    In an effort to keep you, our volunteers, and community as safe as possible, please review the indicator symptoms below Identifying if you have experienced any of the following within the past 14 days.  

50. Check if you have any symptoms

    1. Cough
    2. Shortness of breath or difficulty breathing
    3. Fever
    4. Chills
    5. Repeated shaking with chills
    6. Muscle pain
    7. Sore throat
    8. New loss of taste or smell

52. If you have a cough and shortness of breath or difficulty breathing, these symptoms may indicate you may have been exposed to and may test positive for COVID-19. In exercising an abundance of caution, please do not volunteer for our event. Continue to monitor your health conditions closely and seek medical attention if necessary.

    If you have at least two of the remaining symptoms in the list above, you may also have been exposed to COVID- 19 and we ask that you do not volunteer for our event at this time. Continue to monitor your health conditions closely and seek medical attention if necessary.

    Thank you for taking this pre-volunteer health screening and keeping yourself, your family, and community safe. Please let us know if you will not be able to volunteer at this time so we can update our volunteer registration list.

    ¹ https:/ / www.cdc.gov/coronavirus/ 2019-ncov/symptoms-testing/symptoms.html

54. VOLUNTEER AGREEMENT & RELEASE FROM LIABILITY

    I agree to volunteer my time and services to work for Keep America Beautiful and the KAB Affiliate Network. As a volunteer:

    1. I control the dates and times when I work with KAB or a KAB Affiliate and they are not responsible for scheduling my volunteer work. I understand I will not be compensated for any time spent volunteering, nor am I entitled to benefits, including employment insurance benefits upon termination of this agreement or as a result of my volunteer service.
    2. I am aware that certain volunteer activities have different levels of physical requirements, i.e. standing, lifting and carrying up to 40 pounds. I will volunteer only for activities matching my abilities and will exercise reasonable care to avoid injury, l acknowledge I am voluntarily agreeing to participate in activities with knowledge of the hazards and potential dangers involved and agree to accept any and all risks of personal injury and property damage. It is my responsibility to withdraw from any activities if I find I am unable to perform them safely.
    3. I will not in any manner discriminate against any person on account of citizenship, life experiences and abilities, learning and working style, personality type, race, socio-economic status, class, gender, sexual orientation, education, country of origin, or cultural, political, religious affiliation.
    4. I agree to report any change in my health status as it relates to the CDC published COVID-19 symptoms (cough, shortness of breath or difficulty breathing, fever, chills, repeated shaking with chills, muscle pain, headache, sore throat, or new loss of taste/smell) for a period of 14 days before and after my volunteer event. It is understood and I grant permission to the event organizer to make a reasonable effort to notify others I may have come into contact while volunteering so they can self-isolate themselves and monitor their own health status. It is understood that event organizers will NOT disclose my personal identity or reported health information.
    5. I agree that l, and my assignees, heirs, guardians, and legal representatives, will not make a claim against or sue Keep America Beautiful or its employees, board members, Affiliates, agents or contractors for injury or damage resulting from the negligence, whether active or passive, or other acts, however caused, by any of its employees, board members, Affiliates, agents or contractors of Keep America Beautiful as a result of my volunteering. I HEREBY RELEASE AND DISCHARGE KEEP AMERICA BEAUTIFUL AND AFFILIATES OF KEEP AMERICA BEAUTIFUL INCLUDING THEIR OFFICERS, BOARD MEMBERS, EMPLOYEES, AGENTS AND CONTRACTORS FROM ALL ACTIONS, CLAIMS, OR DEMANDS THAT I, MY HEIRS, GUARDIANS, AND LEGAL REPRESENTATIVES NOW HAVE, OR MAY HAVE IN THE FUTURE, FROM PROPERTY DAMAGE, BODILY INJURY, AND/OR DEATH RESULTING FROM MY VOLUNTEERING.

    6. I UNDERSTAND THAT IF I AM INJURED IN THE COURSE OF VOLUNTEERING, I AM NOT COVERED BY THE WORKERS' COMPENSATION PROGRAM OF KEEP AMERICA BEAUTIFUL AND AFFILIATES OF KEEP AMERICA BEAUTIFUL. I authorize Keep America Beautiful and Affiliates of Keep America Beautiful to seek emergency medical treatment on my behalf in case of Injury, accident or illness to me arising from my involvement as a volunteer. I understand that I will be responsible for medical costs incurred by such accident, illness or injury.

    7. I HAVE CAREFULLY READ THIS AGREEMENT AND FULLY UNDERSTAND ITS CONTENT. I AM AWARE THAT THIS IS A RELEASE OF LIABILITY, AND SIGN IT OF MY OWN FREE WILL.

56. Date
57. Volunteer/Participate Signature or parent or Guardian if under 18
59. Printed Name/Name of Parent or Guardian if under 18

61. lf Volunteer/Participant is under 18 years of age, parent or guardian must read and also sign: This release, its significance, and assumption of risk have been explained to arid are understood by the minor and myself as attested to and co-signed above.

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64. Email address

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