Junior Anti-Litter Bug Club Member Application Form Junior Anti-Litter Bug Club Member Application Date: (1) Member's FULL Name* Age* Birth Date* (2) Member's FULL Name: Age: Birth Date: (3) Member's FULL Name: Age: Birth Date: (4) Member's FULL Name: Age: Birth Date: Parent/Guardian Full Name* Address: Phone* Email* Where did you hear about the Junior Anti-Litter Bug Club? Newspaper Website Leisure Guide Friend Event Other The Mission Adopt-a-Block Society is supported by the District of Mission and is a cooperative effort between the society and the citizens of the District who wish to contribute to the appearance of their community. Both parties therefore commit to each other to perform certain activities for keeping cleaner and safer streets, trails, parks and creeks. It is understood that at no time is the safety of any volunteer to be compromised in the performance of Junior Anti-Litter Bug Club activities. THE MEMBER(s) & their Parent/Guardian agrees to: 1. Hold up the values of the Junior Anti-Litter Bug Club pledge, by being responsible for your own litter, and encouraging others to do likewise. 2. To remove litter from areas that it doesn’t belong when you see it, using only the proper safety equipment provided by the Junior Anti-Litter Bug Club (picker and collection bag) or likewise. 3. Only participate in Junior Anti-Litter Bug Club activities when adult supervision is provided. At no time can a Junior Anti-Litter Bug Club member be unattended while removing litter in the community. 4. Avoid direct contact with items that have the potential to be hazardous or injurious. Items such as syringes, condoms and animal parts shall not be touched. Hazardous litter and exceptionally heavy or unyielding objects shall be reported immediately to the AAB Coordinator. 5. Notify Mission Adopt-A-Block of any changes to the members contact information including phone number, email and address. THE MISSION ADOPT-A-BLOCK SOCIETY agrees to: 1. Supply Junior Anti-Litter Bug Club materials which may include, but is not limited to, member t-shirts, litter bags, and litter pickers. 2. Arrange for the removal and disposal of any litter and materials collected from the member that cannot be disposed of in weekly removal service. 3. Provide Bi-annual newsletters, educational opportunities and special events for members to attend. I have read and understood this statement of commitment, and I agree to the terms of participation. By signing your name you consent to the above stated* Release and Waiver Agreement Adopt-A-Block (Junior Anti-Litter Bug Club) Program By signing this document you waive certain rights including the right to sue. PLEASE READ CAREFULLY. TO: THE CORPORATION OF THE DISTRICT OF MISSION, ITS OFFICERS, EMPLOYEES, DIRECTORS and VOLUNTEERS AND THE MISSION ADOPT-A-BLOCK SOCIETY (together called "THE RELEASEES"). ASSUMPTION OF RISK I am aware that my child will be engaging in an Adopt-A-Block activity including those performed under the Junior Anti-Litter Bug Club that may involve certain risks, dangers and hazards, including, but not limited to picking up dangerous debris and collision with passing traffic. I agree to ensure my child wears a safety vest (JBC t-shirt) and uses proper tools (such as gloves, tongs and/or EZ Reachers) while participating to minimize any such risks and I freely accept, and fully understand and assume all risks and dangers and the possibility of personal injury, death, property damage or loss resulting therefrom including NEGLIGENCE, BREACH OF CONTRACT; OR BREACH OF ANY STATUTORY OR OTHER DUTY OF CARE, INCLUDING ANY DUTY OF CARE OWED UNDER THE OCCUPIERS LIABILITY ACT R.S.B.C. 1996, C.337 on the part of the Releasees. RELEASE OF LIABILITY, WAIVER OF CLAIMS AND INDEMNITY AGREEMENT By participating in the Adopt-A-Block, Junior Anti-Litter Bug Club program I hereby agree as follows: 1. TO WAIVE ANY AND ALL CLAIMS that I or my child have or may in the future have against the Releasees. 2. TO RELEASE THE RELEASEES from any and all liability for any loss, damage, injury or expense that my child may suffer or that my next of kin may suffer as a result of participating in the Adopt-A-Block program due to any cause whatsoever, including negligence on the part of the Releasees and including NEGLIGENCE, BREACH OF CONTRACT, OR BREACH OF ANY STATUTORY OR OTHER DUTY OF CARE, INCLUDING ANY DUTY OF CARE OWED UNDER THE OCCUPIERS LIABILITY ACT R.S.B.C. 1996, C.337 on the part of the Releasees. 3. TO HOLD HARMLESS AND INDEMNIFY THE RELEASEES for any and all liability for any property damage or personal injury to any third party, resulting from my childs participation in the program. 4. This Release shall be effective and binding upon my childs heirs, next of kin, executors, administrators and assigns, in the event of my child's death. I have read this Release prior to signing it and I understand its effect. I am aware that by signing this Release I am waiving certain legal rights which my child or next of kin, executors, administrators and assigns may otherwise have had against the RELEASEES. By signing your name you consent to the above stated* 3+4=?