Air Quality Program Liability Waiver
Please complete this form to participate in the Air Quality Program. Your responses help us ensure your safety and understanding of program risks.
Full Name
*
First Name
Last Name
Email Address
*
example@example.com
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Date of Birth
*
-
Month
-
Day
Year
Date
Emergency Contact Name
*
First Name
Last Name
Emergency Contact Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Do you have any allergies or medical conditions we should be aware of?
Which Air Quality Program activity will you participate in?
*
Please Select
Outdoor Air Sampling
Indoor Air Quality Monitoring
Air Quality Workshop
Community Presentation
Other
Please list any special accommodations you require to participate.
Participant Signature
*
Date Signed
*
-
Month
-
Day
Year
Date
Submit Waiver
Submit Waiver
Should be Empty: