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Mandatory Participant info- 2017 CA Specialty Crops Tour
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Last Name:
First Name*
Agency
Divfsion/Oroup/eic.;
Title:
Street:
CMylState/ ZIP
Rhone:
E-mail:
Years in Present Position:
Your Cell Phone Number:
Emergency Contact Person:
Relationship to you:
I Emergency Contact Phone Number:
| Dietary Needs/ Restrictions:
| Any medical /physical/ to. limitations:
Your Supervisor's Name;
Supervisor's E-mail Address:
Supervisor's Phone Number:
To the best of my knowledge, I am in good physical condition and fully able to participate in this tour. 1 am fully aware of the risks and hazards connected with the participation in this event, including physical injury or even death, and hereby elect to voluntarily participate in said event, knowing that the associated physical activity may be hazardous to me and my property.
I VOLUNTARILY ASSUME FULL RESPONSIBILITY FOR ANY RISKS OR LOSS, PROPERTY DAMAGE, OR PERSONAL INJURY, INCLUDING DEATH, that may be sustained by me, or loss or damage to property owned by me, as a resuft of participation In this tour.
In signing this release, I acknowledge and represent that I HAVE READ THE FORGOING Waiver of Liability and Hold Harmless Agreement, UNDERSTAND IT AND SION IT VOLUNTARILY.
Signature Sierra Club v. EPA 18cv3472 NDCA
Tiers 8&9
Date ED 002061 00044413-00001