S TATEMENT OF AGE AND RELEASE OF LIABILITY I

EMPLOYEES’ COMPENSATION DIVISION LABOUR DEPARTMENT STATEMENT OF
STATEMENT ON RESTITUTION
VICTIM IMPACT STATEMENT

PROJECT NAME NJDOT SCOPE STATEMENT TSM LIMITED SCOPE FINAL
INFOSTMT INFORMATION STATEMENT ASSOCIATIONS INCORPORATION ACT
2 DEXIA SENT THE FOLLOWING STATEMENT TO

STATEMENT OF AGE AND RELEASE OF LIABILITY

S TATEMENT OF AGE AND RELEASE OF LIABILITY

I, __________________________________________________ hereby state and certify as follows:

1. I am 18 (eighteen) years of age or older and competent to sign this Statement of Age and Release of Liability.

2. I wish to be involved in the _____________________________ Park Project. I recognize the inherent dangers associated with working at the Park and in particular the risks associated with performing work in an area that may be dangerous and potentially life threatening. I also recognize that there are latent and obvious dangers present at the Park that my result in serious injury or possibly death to me. I assume the responsibility of determining the condition of the Park prior to performing any work.

3. In consideration of the Metropolitan Park District of Tacoma allowing me access to the Park, I do hereby, for myself, my spouse, my children, my heirs, executors and assigns, release the Metropolitan Park District of Tacoma and the officials, officers, agents, employees and volunteers of the Park District from liability from any harm, injury or damage which I may suffer as a result of accessing or working at the Park. This includes all risks that are connected with this activity whether foreseen or unforeseen.

4. I agree to indemnify and hold the Metropolitan Park District of Tacoma and its officers, agents, officials, employees and volunteers harmless from any damage to persons or property, resulting from the negligence and/or intentional act of myself. I further agree to indemnify and hold the Metropolitan Park District of Tacoma and its officers, agents, officials, employees and volunteers harmless from any and all claims, suits, actions, liabilities, losses, demands, damages, expenses, including legal expenses, by my spouse, my children, my heirs, executors and assigns.

5. I, the undersigned, hereby expressly agree that this release and waiver is intended to be as broad and inclusive as permitted by the laws of the State of Washington and if any portion hereof is held invalid, it is agreed that the balance shall, notwithstanding, continue in full legal force and effect.

6. I have fully informed myself of the contents of this release by reading it before I sign it. I realize that by signing this document I am giving up legal rights which I may be entitled to.

Signed by:

Date:

2 OPENING STATEMENT CHAIR OF THE SEVENTH
DESIGN AND ACCESS STATEMENTS IN ACCORDANCE WITH
EMPLOYMENT OF EXOFFENDERS POLICY POLICY STATEMENT CHICHESTER

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