Adopt-a-Stop Waiver Form

Hidden Contact Name

First NameLast Name

Hidden Contact Email

example@example.com

The undersigned Volunteer has reviewed the Safety Rules for GTA’s Adopt-a-Stop Program and agrees to assume all risks in carrying out such activities as associated with this program. The Volunteer agrees to indemnify and save harmless the City from any claims of damages to persons or to property or for death arising out of Volunteer activities carried out pursuant to this Program.

Name of Organization/Group/Business

Please scroll down to the first empty Name field, and complete the Name, Minor (Yes/No) and Signature fields, and repeat for each member of your party. Then click scroll down to the bottom and click Submit Signature(s).

Note: The limit for this form is 20 signatures.

To add more signatures, please contact GTA at 336-412-6309.

Does this form need to be forwarded to other members of your group for additional signatures?

YesNo

How many additional members?

Please list up to 10 email addresses, separated with a comma.

Please separate each email address with a comma.

Please list additional email addresses, up to 10, separated with a comma.

Please separate each email address with a comma.

1. Name

First and Last Name

Is this volunteer a minor?

Signature

2. Name

First and Last Name

Is this volunteer a minor?

Signature

3. Name

First and Last Name

Is this volunteer a minor?

Signature

4. Name

First and Last Name

Is this volunteer a minor?

Signature

5. Name

First and Last Name

Is this volunteer a minor?

Signature

6. Name

First and Last Name

Is this volunteer a minor?

Signature

7. Name

First and Last Name

Is this volunteer a minor?

Signature

8. Name

First and Last Name

Is this volunteer a minor?

Signature

9. Name

First and Last Name

Is this volunteer a minor?

Signature

10. Name

First and Last Name

Is this volunteer a minor?

Signature

11. Name

First and Last Name

Is this volunteer a minor?

Signature

12. Name

First and Last Name

Is this volunteer a minor?

Signature

13. Name

First and Last Name

Is this volunteer a minor?

Signature

14. Name

First and Last Name

Is this volunteer a minor?

Signature

15. Name

First and Last Name

Is this volunteer a minor?

Signature

16. Name

First and Last Name

Is this volunteer a minor?

Signature

17. Name

First and Last Name

Is this volunteer a minor?

Signature

18. Name

First and Last Name

Is this volunteer a minor?

Signature

19. Name

First and Last Name

Is this volunteer a minor?

Signature

20. Name

First and Last Name

Is this volunteer a minor?

Signature