Goshen Township

14003 W. South Range Rd.

Salem, OH 44460-9127

330-332-1235

WAIVER AND RELEASE

I have read and understand the Rules and Regulations of the Goshen

Township Trustees on the use of any of Goshen Township Buildings or

Grounds and agree to comply with the same.

For and in consideration of the permission to use the property owned

by Goshen Township, Mahoning County, Ohio, I the undersigned agree

to release, acquit, discharge and covenant to hold harmless Goshen Township,

its Board of Trustees, officers, employees, servants, and agents of and from

any and all actions, causes of action, claims, demands, damages, costs,

loss of services, expenses and compensation, on or account of, or in any way

growing out of, any and all personal illness or injury or property damage

which may result to any group or organization member as a result of the

participation in any activity at the property owned by Goshen Township.

Organization Name (if applicable) _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _

Printed Name: _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _

Signature: _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _Date: _ _ _ _ _ _ _

- - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - -

OFFICE USE ONLY

Date or Dates Location Rented / Used _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _

Fee: $_ _ _ _ _ _ _ Deposit: $_ _ _ _ _ _ _ Refund: $ _ _ _ _ _ _

Signature of Township Representative: _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _