Clean Drains Fort Wayne COMPLETED MARKED DRAIN FORM 2023 (Business/Individual)

Your Name*

Your Name or Business/Organization

Your Email*

example@example.com

Your Phone*

Please enter a valid phone number.

Please share the number of storm drains you MARKED:*

More information about drain marking can be found on the website.

PARTICIPANTS MUST MARK ON THE MAP THE DRAINS THEY MARKED, AND UPLOAD THE MARKED MAP BELOW:

PLEASE UPLOAD YOUR MAP OF THE DRAINS YOU MARKED (map is included in the kit you received)*

DO YOU HAVE EXTRA DRAIN MARKING SUPPLIES? IF SO PLEASE LET US KNOW.

YESNO

For more information contact Irene Walters at irenewalters1@gmail.com.

WAIVER & CONSENT TO PARTICIPATE*

By checking this box, you acknowledge and agree you are participating in the 2022 Clean Drains Program (“Program”) on a voluntary basis and your participation may involve risks inherent to the activities being undertaken in connection with the Program. You acknowledge that you knowingly and willingly accept such risks and that the City of Fort Wayne and Friends of the Rivers shall have no liability related to your participation in the Program whatsoever. By checking this box, you agree to release, discharge, and hold harmless the City of Fort Wayne and Friends of the Rivers, and each of their respective employees, agents, and representatives, of and from all liabilities, claims, actions, damages, costs or expenses of any kind arising out of or relating to your participation in the Program, whether as a result of bodily injury, property damage, or death. You further acknowledge that this release includes any claims, actions, damages, costs or expenses based on the actions, omissions, or negligence of the City of Fort Wayne and Friends of the Rivers, and each of their respective employees, agents, and representatives.

2023 CLEAN DRAINS FORT WAYNE