EXHIBIT A (PAGE 3)
KEEP CHARLOTTE BEAUTIFUL, INC. ADOPT-A-ROAD PROGRAM
CONSENT AND RELEASE FORM
I am the parent or legal guardian of _____________________________, a minor (hereinafter "my child"), who
is a member of the ________________________and I have read and understand the terms and conditions
contained in the Keep Charlotte Beautiful, Inc. Adopt-A-Road Agreement and the Roadside Safety
Recommendations prior to my child's participation in litter removal in the County rights-of-way. I hereby consent to
my child's participation in litter removal in the County rights-of-way in accordance with the Keep Charlotte Beautiful,
Inc. Adopt-A-Road Agreement. I agree to instruct my child to follow and conduct him/herself according to all the
terms and condition of the Keep Charlotte Beautiful, Inc. Adopt-A-Road Agreement and the Roadside Safety
Recommendations.
I do hereby release and discharge Keep Charlotte Beautiful, Inc. and all of Keep Charlotte Beautiful’s officers,
directors, and employees from all liabilities, claims, demands, and causes of action of every kind whatsoever for any
damages and or injuries arising from any cause whatsoever which may result directly or indirectly from my child's
participation in the Keep Charlotte Beautiful, Inc. Adopt-A-Road program.
I further agree to hold harmless Keep Charlotte Beautiful, Inc. and its officers, agents, and employees from
liability for any damages or injuries resulting from any acts or failure to act on my child's part during my child's
participation in any Adopt-A-Road activities on or near Charlotte County rights-of-way.
_________________________________ ________________________________
Signature of Parent/Legal Guardian Signature of Parent/Legal Guardian
_________________________________ ________________________________
Typed/Printed Name Typed/Printed Name
Date:____________________________ Date:___________________________