| Name______________________________ | Year Retired _______________ |
| Spouse/Significant Other___________________ | Phone (______)___________________ |
| Street/Apartment____________________ | Email address (please print clearly) |
| City_________________________________ | _______________________________ |
| State & ZIP_________________________ | |
|
LLESA RELEASE AND INDEMNITY AGREEMENT (Required for attendance at functions) | |
|
I voluntarily participate in LLNL Retiree Networking Group activities that include meetings, classes, trips, and special social events. I am aware that certain dangers and hazards are incidental to these activities including possible injury and loss of life. Some of these dangers include tripping, slipping, and falling, vehicle accidents and accidents related to traveling to and from the excursion site(s). It is my intention to exempt and relieve LLESA, Inc., Lawrence Livermore National Security LLC, National Nuclear Security Administration and the Department of Energy, their agents, officers, employees, and subcontractors from liability for personal injury, property damage or wrongful death from negligence or other acts, howsoever caused. I agree that in the event any claim for personal injury, property damage, or wrongful death shall be prosecuted against LLESA, Inc., Lawrence Livermore National Security LLC, National Nuclear Security Administration and the Department of Energy, their agents, officers, employees, or subcontractors, I, my assignees, heirs, distributes, guardians, and legal representatives shall indemnify and hold the above named and their agents, officers, employees, subcontractors (independent or otherwise) harmless from any and all claims or causes of action by whomever or wherever made or presented for personal injuries, property damage, or wrongful death. | |
| I agree to the above statements by signing my name here: | ______________________________________ | Spouse/Other: | ______________________________________ |
| Date: | _____________ |
| Please print this form in your browser. | |
| Make check payable to: | LLNL Retirees |
| Mail to: |
LLNL Retirees P.O. Box 2170 Livermore, CA 94551 |