Gratuitous Services Agreement and Volunteer Release and Hold Harmless

Office of Infrastructure Protection

National Protection and Programs Directorate

U.S. Department of Homeland Security

Washington, DC 20528

VOLUNTEER PARTICIPANT RELEASE OF LIABILITY AGREEMENT

Paperwork Reduction Act: The public reporting burden to complete this information collection is estimated at 6 minutes per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and the completing and reviewing the collected information.  An agency may not conduct or sponsor, and a person is not required to respond to a collection of information unless it displays a currently valid OMB control number and expiration date.  Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden to DHS/NPPD/IP/PSCD/OBP, 245 Murray Lane SW., Mail Stop 0612, Washington, DC 20528–0612 or [email protected]. ATTN: 1670-NEW.

Privacy Act Notice:

Authority: 5 U.S.C. § 301 and 44 U.S.C. § 3101 authorize the collection of this information.

Purpose: DHS will use this information to improve products and contact you regarding your response.

Routine Use: This information may be disclosed as generally permitted under 5 U.S.C. §552a(b) of the Privacy Act of 1974, as amended. This includes using the information, as necessary and authorized by the routine uses published in DHS/ALL-002 - Department of Homeland Security (DHS) Mailing and Other Lists System of Records (November 25, 2008, 73 FR 71659).

Disclosure: Furnishing this information is voluntary; however failure to provide any of the information requested may prevent the National Protection and Programs Directorate (NPPD) from contacting you regarding your response.

VOLUNTEER PARTICIPANT RELEASE OF LIABILITY AGREEMENT

In consideration of my participation in [NAME OF ACTIVITY] conducted by the U.S. Department of Homeland Security at [LOCATION] on/from [DATE(S)]

I, the undersigned, agree to release, indemnify, and hold harmless the United States of America and the Department of Homeland Security from any and all liability for personal injury that may occur as a result of my participation in the abovementioned activity, and/or engaging in activities for United States Government purposes, and/or entering upon United States Government property.

I agree to these terms in return for my participation in the abovementioned activity. I understand that by signing this Release I am waiving certain legal rights to sue or assert any cause of action against the United States and the Department of Homeland Security. I understand fully the consequences of this waiver and acknowledge I have had the opportunity to have this document reviewed by my legal counsel. I certify that I am at least 18 years of age and I have read the Release in its entirety, understand it, and sign it freely and voluntarily, agreeing to be legally bound by the terms and conditions of this document. I understand what will be involved in [NAME OF ACTIVITY]. My role in [NAME OF ACTIVITY] has been fully explained to me.

Print Name Date

Signature

OMB Control Number: 1670-NEW

Expiration Date: XX/XX/XXXX