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2. Town of Fort Mill Adopt-a-Stream Litter Program

   Note: All Adopt-a-Stream clean-up participants must sign this form. Signature of a parent/guardian is required if participant is less than eighteen (18) years of age. 

   Please read the form carefully.  By typing your name and submitting this form, you are electronically signing this waiver.  Paper versions are also available if you prefer. 

4. Adopting Group*

   The name of the group or organization with which you are participating in this Adopt-a-Stream clean up

5. Stream Section

   Name of stream or identifying location, if known to participant

7. Informed Consent, Liability & Hold Harmless, Publicity Permission

   I understand that on one or more occasions I/my child will be performing stream clean-up work as part of the Town sponsored Adopt-a-Stream program. 

   Said work will be performed with the support and direction of the above-mentioned Adopting Group participating in the Adopt-a-Stream program. 

   I have read, and am familiar with, the Adopt-a-Stream General Program Conditions and Safety Guidelines provided to me by the Adopting Group, and agree to comply with said conditions and guidelines. 

   I understand that stream clean-up activities have a potential risk of injury. 

   I agree that I/my child will only perform those activities that I am/my child is capable of doing and able to do, and I acknowledge and assume the risks of all such activities. 

   I understand that participation in the stream clean-up activities is strictly voluntary and that I/my child may cease the volunteer activity at any time. 

   I agree that I will not hold the Adopting Group or the Town of Fort Mill or any of its agents, officers, employees, or representatives responsible for any damage or injury to me/my child or my/my child’s property as a result of volunteer participation in the Adopt-a-Stream program. I further agree to release, indemnify and hold harmless the Adopting Group and the Town of Fort Mill and all of its agents, officers, employees, representatives, successors and assigns from any and all damages, claims and/or liability arising out of my/my child’s activities as a volunteer stream clean-up participant in the Adopt-a-Stream program. 

   I give permission to the Town of Fort Mill Stormwater Department to include me/my child in any video productions or photographs that are made to document or publicize the Adopt-a-Stream activities. 

9. Informed Consent*

   By checking the box, you are accepting the terms and conditions in this waiver of consent, liability & hold harmless and publicity policy. 

   1. I agree to the above
11. Participant First Name*
12. Participant Last Name*
14. Participant Phone Number*
15. Participant Email*
17. Signature of Participant (over age 18) or Signature of Parent/Guardian*

    If the participant is over age 18, please sign.  If participant is under age 18, a parent/guardian must sign

18. Date*
    Date
20. Parent/Guardian First Name

    If signed by a parent/guardian

21. Parent/Guardian Last Name

    If signed by a parent/guardian

25. Emergency Contact*
27. Phone Number*
28. Relationship to Participant*
30. Email Address*
Leave This Blank:


32. 1. Receive an email copy of this form.
33. Email address

    This field is not part of the form submission.

34. Submit Submit and Print

* indicates a required field