Adopt-A-Highway Program

Name *

First Name Last Name

Address *

Street Address

Street Address Line 2

City State / Province

Primary Phone Number *

Area Code Phone Number

Secondary Phone Number *

Area Code Phone Number

E-mail *

Are you 18 years or older? *

Yes No

Areas of Interest *

Please explain your "other" Interests

Have you been convicted of any crime in past seven years? *

Yes No

Please Note: No applicant will be denied opportunity to volunteer solely on the grounds of conviction of a criminal offense. The nature of the offense, the surrounding circumstances and the relevance of the offense will may, however, be considered.

Please Explain your conviction

Special Skills or Qualifications:

Skills and qualifications can be acquired through employment, previous volunteer work, or other activities such as hobbies or sports. What skills or qualifications do you have as a volunteer?

Your Community Affiliations (Clubs, Service Organizations, etc.)

When are you available for volunteer assignments? *

Please include the days of the week and the times available on those days

Receive BEMS Email Newsletter?

Yes No

BROWNSTOWN/EWING MAIN STREET WAIVER:

I hereby release, indemnify, and hold harmless Brownstown/Ewing Main Street and their respective officers, directors, employees, agents, contractors, subcontractors, representatives, successors and assigns, and all persons conducting directly or indirectly, the activities surrounding my involvement as a volunteer from any and all claims, rights, demands, action, cause of action, expenses and damages, which I or my heirs, personal representative, successors, assigns or anyone claiming by, through or under me ever had, now have, or may have against the parties identified above arising from any injury, act or omission relating in the way to my participation as a volunteer.

I understand that I am to receive no payment for services from the Brownstown/Ewing Main Street program. I am not an employee. I will not be entitled to and will not receive Worker’s Compensations benefits or other similar payments from the Brownstown/Ewing Main Street under the law of the State of Indiana in the event that I am injured.

I hereby consent that Brownstown/Ewing Main Street, in conjunction with their volunteer program, to copyright, publish, use, sell or assign any and all photographic portraits or pictures, television spots, movie films, videotapes, and/or sound records or any part thereof, that they may take or make of me during my work as a volunteer in which I may be included in whole or in part, whether separate from or in conjunction with, illustrative or written manner, story or news item, motions pictures, television or radio spots, or for publicity, advertising or any other lawful purpose whatsoever, in conjunction with my name or in anonymity. I hereby waive any right I may have to inspect and/or approve the finished product or the advertising copy that may be used in connection therewith or the use to which it may be applied.

I hereby waive all claims for compensation of such use or for damages.

Signature of Participant *

Clear

Signature of Parent or Guardian if under 18 years of Age

Clear

Today's Date *

Month Day Year

Brownstown/Ewing Main Street Volunteer Program

BROWNSTOWN/EWING MAIN STREET WAIVER: