CITIZENS ACADEMY APPLICATION

PLEASE COMPLETE THE FOLLOWING

Full Name: Date of Birth:
Mailing Address: City, State ZIP:     
Home Phone: Business Phone:
E-mail Address:

Release and Waiver

The Citizens Academy Participant hereby releases and forever discharges and holds harmless the Commissioners of St. Mary’s County, its departments, boards, commissions, agents, employees and representatives, from any and all liability, claims, and demands of whatever kind and nature, either in law or equity, whether for bodily injury, personal injury, illness, death, invasion of privacy or property damage, which arise or may hereafter in connection with the Citizens Academy participation.

The Citizens Academy Participant also understands that St. Mary’s County Government does not carry, maintain or provide health, medical, or disability insurance coverage for any participant and does not assume any responsibility or obligation to provide financial or other assistance, in the event of injury or illness suffered by participation. Each participant is expected and encouraged to obtain his or her own medical, health and disability insurance.

Citizens Academy Participant agrees that, in the event that any clause or provision of this Release and Waiver of Liability shall be held to be invalid, the invalidity of such clause or provision shall not otherwise affect the remaining provisions of this Release and Waiver of Liability, which shall continue to be enforceable.

Participant Signature:

Date:

Media

I authorize St. Mary’s County Government to use my image and/or voice in any media form (including, but not limited to, cable television broadcasts, videos, internet communications, and publications). I release the Commissioners of St. Mary’s County from any and all claims and liability regarding the making or use of any audio/or visual recording of my image and/or voice (including claims related to rights of publicity or privacy, defamation, or portrayal in a false light, whether intentional or unintentional).

Participant Signature:

Date:

Completed applications may also be returned to:

St. Mary's County Government
P.O. Box 653
Leonardtown, MD 20650
Attn: SMCG Citizens Academy
Via Email to: smcgcitizensacademy@stmarysmd.com