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2. Hold Harmless Agreement
   THE UNDERSIGNED HEREBY requests permission from the City of Las Cruces and Las Cruces Fire Department (LCFD) to participate with LCFD in the following program/activity:
4. Check One*

   1. Third Rider/Observer Program
   2. Physical Training Workshop

   1. Physical Performance Assessment/ Acrophobia Climb
   2. DACC Field Clinicals
6. THE UNDERSIGNED HEREBY
   recognizes that there are many risks of injury to the undersigned, both from the activities of LCFD as well as from the activities of third parties. In order to induce the City and LCFD to grant such permission, the undersigned does hereby agree to hold harmless and indemnify the City and LCFD from any and all claims, injuries or damages which the undersigned may sustain while participating in such fire and emergency activity and does waive any right of which the undersigned might have to pursue a claim against the City or LCFD for any such claims, injuries or damages. IF OVER 18 YEARS OF AGE, APPLICANT MUST SHOW PROOF OF AGE.
8. First Name*
9. Last Name*
11. First Name (of Parent or Guardian)
12. Last Name (of Parent or Guardian)
14. Name of the Organization with which you are affiliated.*
16. Address*
18. City*
19. State*
20. Zip Code*
22. Phone Number*
24. Email Address
26. Electronic Signature Agreement

    By checking the "I agree" box below, you agree and acknowledge that 1) your application will not be signed in the sense of a traditional paper document, 2) by signing in this alternate manner, you authorize your electronic signature to be valid and binding upon you to the same force and effect as a handwritten signature, and 3) you may still be required to provide a traditional signature at a later date.

    1. I agree.
28. Electronic Signature
30. 1ST Date and Time Requested*
    1ST Date and Time Requested

    1ST Date and Time Requested
31. 2ND Date and Time Requested*
    2ND Date and Time Requested

    2ND Date and Time Requested
32. 3RD Date and Time Requested
    3RD Date and Time Requested

    3RD Date and Time Requested
Leave This Blank:


34. 1. Receive an email copy of this form.
35. Email address

    This field is not part of the form submission.

36. Submit

* indicates a required field