Mirrormont Pea Patch Application

& Hold Harmless Agreement

Name(s): _____________________________________________________      Day Phone: _______________________

______________________________________________________    Day Phone: _______________________

Street Address: _____________________________________________ Evening Phone: ___________________

Email(s): _______________________________________________________________________

MCA member:   yes/no          Agree to abide by Garden Rules:  yes/no

Number of framed beds: __________   Unframed: 8×8 plots: _________ 8×16 plots: ___________

Fees: Up to three framed beds (96 sq ft) $15; 8×8 plot 64 sq ft) $10; 8×16 plot (128 sq ft) $15

Plot #: ___________________            Amount paid: _____________________

In case of emergency, please contact:

Name: ______________________________________________________            Relationship: _____________________

Phone: Day _______________________________________            Evening ____________________________________

For the year of March 1, 2010 through March 1, 2011, the undersigned on behalf of themselves, their family members, and their estate, hereby waives any right of recovery and releases Mirrormont Community Association (MCA) and Mirrormont Country Club (MCC), their officers, officials, employees and agents, from liability related to the Undersigned, arising from any and all injury to persons and damage to property, and further agrees and undertakes to indemnify, hold harmless and defend the MCA & MCC from and against any and all claims, damages, actions, liability and expenses including attorney’s fees and other professional fees in connection with bodily injury including death, personal injury and/or damage to property arising from or out of the Undersigned’s activities and participation in gardening and volunteer services at the Mirrormont Pea Patch.

The Undersigned further acknowledges and agrees that the MCA & MCC do not assume any responsibility whatsoever for any property of the Undersigned and the Undersigned shall not hold the MCA or MCC liable for any loss or damage to same.  The undersigned give their permission to be photographed and have their image used in MCA or MCC publications.

Gardener(s) Signature(s): ___________________________________            Date: _________________

___________________________________            Date: _________________