HomeMy WebLinkAboutDiamond Ride Application_Redacted.pdfInstructions: Residents 60 years and older complete items 1-3 and 5, and sign
on Page 2. Residents with disabilities complete items 1-5 and sign on Page 2.
1. General Applicant Information ❑ New Application ❑ Renewal (ID# )
Last Name: ': First Name: J 1 n
Address: Apt #:
City: ( Zip: —IG
Home Phone: q(),q5�,.,.,..
OOL�- Wale ❑Female Date of Birth: /()
2. Emergency Contact Information
Please list two contact people to be notified in case of an emergency.
Contact 1: Contact 2:
Relationship: Relationship:
Home Phone:
Home Phone:
Cell Phone:,:. Cell Phone:
3. General Eligibility Information— Required
Dri er's License or government issued identification card showing proof of age and residency
4. Disability Eligibility Information — Provide one of the following:
❑ Medicare Identification Card
❑California Department of Motor Vehicles Disabled Person Identification Card
❑ Disabled Veterans Identification Card
❑ Proof of SSIISSDI Benefits (Copy of award letter, benefit adjustment, or benefit check)
❑ Completed Medical Professional Certification may be submitted in lieu of one of the above listed
certification documents
5. Certification — I hereby certify the information 1 have given in this application is correct.
Signature: Date:
WAIVER, RELEASE AND DISCHARGE OF LIABILITY
In consideration of my being permitted to enroll and participate in Diamond Ride ("said activity"
herein) sponsored by the City of Diamond Bar, I hereby voluntarily waive, release and discharge in
advance any and all actions or causes of action and claims for personal injury, property damage, or
wrongful death which I may have, or which may hereafter accrue to me, my heirs or aoy other
successors in interest as a result of my participation in said activity including activities incidental
thereto, and for whatever period said activity may continue. This release is intended to the fullest
extent permitted by law, to waive, release and discharge in advance the City of Diamond Bar and
their respective elected officials, officers, employees and agents (hereafter "Discharged Parties")
from any liability for personal injury, property damage or wrongful death caused by any act or
omission by such Discharged Parties.
I understand that serious and minor accidents occasionally occur during said activity and that
participants occasionally sustain fatal or serious personal injuries and as a consequence I assume
those risks and agree that under no circumstances will I or any of my heirs, assign or any other
successors in interest prosecute any civil action or present any claim for personal injury, property
damage or wrongful death against the Discharged Parties who, through negligence or oterwise,
might otherwise be liable to me, or my heirs, or other successors in interest for damages.
I further agree, for myself and on behalf of my heirs and any other successors in interest, that in the
event any claim for personal injury, property damage or wrongful death shall be prosecuted against
the Discharged Parties or any of them, as a result of my participation in said activity, I shall
indemnify and hold harmless the Discharged Parties from any and all liability, claims and/orwrongful
death.
PRINT PARTICIPANT'S NAME:
SIGNATURE OF PARTICIPANT:
DATE: