Gleaning Form (Participant

)
Gleaning Date: 9/13/2014
Name: _______________________________________________________________________________
Family Members Present: ________________________________________________________________
Street Address/PO Box: _________________________________________________________________
City: _______________________________ County: ________________ State: _____ Zip: ___________
Home Phone: (
) ______- ____________ Cell Phone: (
)______-____________
Work Phone: (
)______-_____________ Email: ___________________________________________
Emergency Contact: _______________________________________
Relationship: _____________________________________________
Phone: __________________________________________________
Secondary Phone: _________________________________________
Release and Waiver of Liability, Assumption of Risk and Indemnity
Safety is of paramount importance in a gleaning event. For the protection of all
involved, this disclaimer is necessary.
I, for myself, for personal representatives, assigns, heirs and next of kin:
1. I acknowledge, agree, and represent that I understand the nature of gleaning activities
and that I am qualified, in good health, and in proper physical condition to participate in
such an activity. I further agree and warrant that if at any time I believe conditions to be
unsafe, I will immediately discontinue further participation in this activity.
2. I acknowledge that I have elected to participate in an activity that includes some risk of
injury. I hereby release, discharge, and covenant not to sue Roadrunner Food Bank (RRFB),
The Storehouse, New Mexico State University, Sandoval County Extension, the Sandoval
County Master gardeners, Seed2Need, its membership, their respective administrators,
directors, agents, officers, members, volunteers and employees, other participants, any
sponsors, and owner and lessors of premises on which the activity takes place (each
considered one of the "releases" herein) from all liability, claims, demands, losses, or
damages on my account caused or alleged to be negligent rescue operations and I further
agree that if, despite this release and waiver of liability, assumption of risk and indemnity
agreement I, or anyone on my behalf, makes a claim against any of the Releases, I will
indemnify, save and hold harmless each of the releases from any litigation expenses,
attorney fees, loss, liability, damage or cost which may incur as the result of such claim.
Photo Release
Also, to encourage the continuation and expansion of gleaning events, I hereby give anyone
involved with the event, with the approval of RRFB or Seed2Need, the right and permission
to copyright and/or use, reuse and/or publish and/or republish pictures or images of me for
the purpose of illustration, advertising and promoting gleaning events and/or participants
working with and supporting RRFB and Seed2Need in those events.
Children You are Signing For:
__________________________________________

______ ________________________________________

__________________________________________

_______________________________________________

Signature: _____________________________________ ___________ _______Date:______________

(Participant or Parent/Guardian for children under the age of 18)