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Mandatory Participant Info 2017 CA Specialty Crops Tour
Last Name:
First Name:
Agency: Division/Groupfate.: Title:
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Street; City/State/ ZIP Rhone: E-maii: Years in Present Position:
Your Cell Phone Number: Emergency Contact Person: Relationship to you: Emergency Contact Phone Number: Dietary Needs/ Restrictions:
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Ex. 6
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Ex. 6
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Ex. 6
Ex. 6
Arty medical /physical/ etc. limitations:
Your Supervisors Name: Supervisor's E-mail Address: Supervisor's Phone Number;
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Ex. 6
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ro h 08St of Knowledge, I am in good physical condition and fully able to participate in this tour. I 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 DmMa GE, OR PERSONAL INJURY, INCLUDING DEATH, that may be sustained by me, or loss or damage to property owned by me, as a result 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 SIGN IT VOLUNTARILY..
Sign^tpre Sierra Club v. EPA 18cv3472 NDCA
Tiers 8&9
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ED 002061 00050679-00001