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Lakewood Community Garden Registration Form 2013 Garden Plot Program Mail Form to City of Lakewood Parks Recreation Community Services 6000 Main Street SW Lakewood WA 98499 To Register On-line go to lakewoodparksandrec.com Type of Event Garden Plot Rental Gardener First Name Last Name Gardener Address Number Street Name Apt City State Zip Telephone Numbers Home Cell Gardener E-Mail Please check here to show you have read the garden rules and agree to do the following Keep my plot weeded and tended Abide by decisions made collectively by the gardeners who participate in coordinating the garden Follow garden rules and guidelines Clear my plot at the end of the gardening season. Agree to let my photo be used for publicity purposes. Annual Gardening Fees Fee for additional plot 20. 00 per year based on availability after 4-1-13 Plot Rental Fee Pd Number of Plots Requested 2013 Date Ck Cash Credit Card I/we assume all risks and hazards incidental to participation in the community garden program including transportation to and from the activities and do hereby waive release absolve indemnify and agree to hold harmless the City of Lakewood and First Baptist Church of Lakewood it s staff instructors officials partners and volunteers for any claim arising from injury to myself or my family members. Furthermore in case of an emergency I give permission for a City of Lakewood representative or designee to secure the emergency medical attention required. I agree that pictures taken may be used for future promotional purposes. Any direction to the contrary should be noted on the registration form and signed. Signature of Gardener responsible for plot Date. Annual Gardening Fees Fee for additional plot 20. 00 per year based on availability after 4-1-13 Plot Rental Fee Pd Number of Plots Requested 2013 Date Ck Cash Credit Card I/we assume all risks and hazards incidental to participation in the community garden program including transportation to and from the activities and do hereby waive release absolve indemnify and agree to hold harmless the City of Lakewood and First Baptist Church of Lakewood it s staff instructors officials partners and volunteers for any claim arising from injury to myself or my family members. Furthermore in case of an emergency I give permission for a City of Lakewood representative or designee to secure the emergency medical attention required* I agree that pictures taken may be used for future promotional purposes. Any direction to the contrary should be noted on the registration form and signed* Signature of Gardener responsible for plot Date. Annual Gardening Fees Fee for additional plot 20. 00 per year based on availability after 4-1-13 Plot Rental Fee Pd Number of Plots Requested 2013 Date Ck Cash Credit Card I/we assume all risks and hazards incidental to participation in the community garden program including transportation to and from the activities and do hereby waive release absolve indemnify and agree to hold harmless the City of Lakewood and First Baptist Church of Lakewood it s staff instructors officials partners and volunteers for any claim arising from injury to myself or my family members. Furthermore in case of an emergency I give permission for a City of Lakewood representative or designee to secure the emergency medical attention required* I agree that pictures taken may be used for future promotional purposes.

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