Volunteer Participant Release of Liability Agreement

DEPARTMENT OF HOMELAND SECURITY

Cybersecurity and Infrastructure Security Agency

OMB Control Number: 1670-0031
Expiration Date: xx/xx/xxxx

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/CISA/ISD/OBP, 245 Murray Lane SW., Mail Stop 0612, Washington, DC 20528–0612
or [email protected]. ATTN: 1670-0031.
Privacy Act Notice:
Authority: 5 U.S.C. § 301 and 44 U.S.C. § 3101 authorize the collection of this information.
Purpose: The DHS Cybersecurity and Infrastructure Security Agency (CISA) will use this information to assess and update Office for Bombing
Prevention (OBP) training opportunities and provide individuals with updated materials and awareness product information following conferences and
other OBP related outreach events.
Routine Use: The information collected will be used by and disclosed to DHS personnel and contractors, to assist in activities related to participation in
DHS/CISA OBP training events.
Disclosure: Furnishing this information is voluntary; however, failure to provide any of the information requested may prevent the DHS/CISA from
contacting you regarding training opportunities and other OBP related outreach events.

In consideration of my participation in
Department of Homeland Security at

conducted by the U.S.
on/from

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 above mentioned 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
. My role in
has been fully explained to me.

Print Name:

Signature:

CISA Form XXX (12/19)

Date:

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