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This form is a PUBLIC RECORD under Chapter 119, Florida Statutes, and is open to public inspection.
If you are interested in participating in the Casselberry Citizen Academy, please complete this form in its entirety.
Street Address (No P.O. Boxes)
*All classes will begin at 6:30 p.m. and will be held at City Hall. Participants must attend 5 out of 6 classes in order to graduate. The program will be limited to 15 individuals and enrollment will be determined on a first come, first serve basis. Participants must be a resident of the City of Casselberry, at least 18 years of age or older, and not currently serving on a City Board, Commission, or Committee. Only one individual from each household will be eligible to participate.*
By checking the "I agree" box below, you agree and acknowledge that you understand the requirements of the program and certify that the information provided is true and complete to the best of your knowledge and belief.
Under Florida law, email addresses are public records. If you do not want your email address released in response to a public records request, do not send electronic mail to this entity. Instead, contact this office by phone or in writing.
I, the undersigned participant, request voluntary participation for myself to participate in the Casselberry Citizen Academy from March 24, 2020 to May 11, 2020 sponsored by City of Casselberry all of which are hereinafter referred to as the "activity".
I consent to participation in the activity and acknowledge that I fully understand my participation may involve risks, without limitation, of serious injury or death, property damage including losses which may result not only from my own actions, inactions or negligence, but also from the actions, inactions, or negligence of others, the condition of the facilities, equipment, or areas where the event or activity is being conducted, and/or the rules of play of this type of event or activity, which I accept and voluntarily incur and assume. I understand that if I have any risk concerns, I should discuss the risks associated with my participation with the activity coordinators and event staff, before I sign this document and before the activity begins.
I certify that I am in good health and have no physical condition that would prevent participation in this activity. Furthermore, I agree to use my personal medical insurance as a primary medical coverage payment if accident or injury occurs. I consent to emergency medical treatment in the event such care is required.
I agree that photographs, pictures, slides, movies, video, or other media coverage of me may be taken in connection with my participation in the activity without compensation from the City of Casselberry, the officers, directors, employees and agents of the City; and, in addition, I consent to the use of photographs, pictures, slides, movies, videos, or other media coverage for any legal purpose.
Despite the risks and in exchange for privileges to participate in these activities, I hereby expressly assume and accept any and all risk involved with my participation in these activities. I agree that I am financially responsible for any losses resulting from my actions and will indemnify the City of Casselberry and the officers, directors, employees and agents of the City, for any loss or damage caused by myself or others during this activity.
In consideration of my participation in the activity, I hereby waive all claims or causes of action against the City of Casselberry and the officers, directors, employees and agents of the City, arising out of my participation in the activity and hereby release, hold harmless, and discharge the City of Casselberry and the officers, directors, employees and agents of the City from all liability in connection therewith.
I have carefully read and reviewed this Waiver, Release, and Hold Harmless Agreement and understand the terms which are governed by the State of Florida. I understand it fully and I execute it voluntarily with the intent to be legally bound hereby for myself and on behalf of my successors, heirs, executors, representatives, administrators, and assigns.
By checking the "I agree" box below, you agree and acknowledge that 1) your application will not be signed in the sense of a traditional paper document, 2) by signing in this alternate manner, you authorize your electronic signature to be valid and binding upon you to the same force and effect as a handwritten signature, and 3) you may still be required to provide a traditional signature at a later date.
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