Display Case Request & Waiver of Liability Ada Community Library

Display Case Request Form & Waiver of Liability

Please fill out the form and you will be contacted by a staff member. Items are displayed on a monthly basis.
At which branch would you like to display your items?*

Lake HazelVictory
In which display case would you like to display your items?

Upstairs (62"wide X 27" deep X 18" high)Downstairs (34" wide X 10" deep with 4 shelves in varying heights of 13", 12", 13", and 16"Downstairs shallow (57" wide X 28" deep X 6" high)
Proposed month to display your items?*
Title of display
Display Description*
The materials are owned by a(n):*

GroupIndividual
Name of individual/group owning materials*
Your name (if different)
Address*
Phone*
Email*
example@example.com
Estimated value of objects*
Owner’s insurance carrier/policy #*
RELEASE AND WAIVER OF LIABILITY
We, (Group's Name)
Group's name
I, (Individual's Name)
Individual's name
understand that Library insurance will not cover the items and materials we place in the Library display case and that the Library cannot accept liability for these items and materials. In consideration of the use of the display case, we hereby fully, absolutely, and unconditionally release, acquit, and forever discharge the Library, and its employees, and trustees from any and all claims, losses, and damages arising out of, pertaining to or in any way related to our use of the display case and Library property. As a condition of use of the display case, we agree to comply with all the rules and regulations regarding use of the display case as listed in the Display Case Policy statement, which rules and regulations are subject to amendment at any time.
SIGNATURE ON BEHALF OF GROUP
SIGNATURE ON BEHALF OF INDIVIDUAL
Group
Signature*

Clear
5/11 MD
Should be Empty:

Display Case Request Form & Waiver of Liability

RELEASE AND WAIVER OF LIABILITY

SIGNATURE ON BEHALF OF GROUP

SIGNATURE ON BEHALF OF INDIVIDUAL

5/11 MD