PERMIT NO.: _____________________
APPLICATION FOR GOLF CART PERMIT
CITY OF LACON
Applicant’s Name: ____________________________________________________________________
Applicant’s Address: __________________________________________________________________
Applicant’s Telephone No. Daytime ( )___________ Night time ( )____________
Applicant’s Driver License No.:_____________________ State: _____________
Applicant’s Insurance Information: ________________________________________________________
Make of golf cart (Mfg):_______________________________________________________________
Color of golf cart: ____________________ Model (Year): _________
Serial Number of golf cart: _____________________________________________________________
I have received, read and understand the “Golf Cart Ordinance.” I have paid the permit fee for the above golf cart. I also understand that the City of Lacon Police Department’s and/or City of Lacon interpretation of all the rules and regulations are final. I will insure that any assigned proof of compliance will remain attached to the golf cart at all times. I furthermore insure that I will obey all the rules and regulations set forth by the City of Lacon concerning the operation of a golf cart within the City limits.
_______________________________________ ___________________________
Applicant’s Signature Date
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FOR CITY USE ONLY
Approved by: ______________________________________________
Date: _______
UNCONDITIONAL AND FULL GENERAL RELEASE OF LIABILITY, WAIVER,
DISCHARGE AND COVENANT NOT TO SUE
DISCHARGE AND COVENANT NOT TO SUE
This is a legally binding UNCONDITIONAL AND FULL GENERAL RELEASE OF LIABILITY, WAIVER, DISCHARGE AND COVENANT NOT TO SUE made by me, _______________________
________________ (hereinafter referred to as Operator) to the City of Lacon (hereinafter referred to as City).
I FULLY RECOGNIZE THAT THERE ARE DANGERS AND RISKS TO WHICH I MAY BE EXPOSED BY OPERATING A GOLF CART ON CITY STREETS. THE FOLLOWING IS A DESCRIPTION AND/OR EXAMPLES OF SIGNIFICANT DANGERS AND RISKS ASSOCIATED WITH THIS ACTIVITY: INJURY TO MYSELF OR OTHERS, DAMAGE TO MY PROPERTY OR THAT OF OTHERS, DEATH OF MYSELF OR OTHERS.
IN NO EVENT SHALL THE CITY BE LIABLE FOR DIRECT, INDIRECT, SPECIAL, INCIDENTAL OR CONSEQUENTIAL DAMAGES; WHETHER ARISING IN TORT, CONTRACT OR ANY OTHER LEGAL THEORY, IN CONNECTION WITH OR ARISING OUT OF OPERATOR’S USE OF A GOLF CART ON CITY STREETS.
THE OPERATOR, AS OF THE DATE BELOW, SHALL HEREINAFTER SAVE, HOLD HARMLESS AND INDEMNIFY THE CITY AGAINST ANY AND ALL LIABILITY, CLAIMS, CAUSES OF ACTION, AND COSTS OF WHATSOEVER KIND AND NATURE INCLUDING, WITHOUT BEING LIMITED TO INJURY, DAMAGE, LOSS INCLUDING DEATH, RESULTING FROM, ARISING OUT OF, OR OCCURRING IN CONNECTION WITH MY USE OF THIS GOLF CART ON CITY STREETS.
I understand that the City has an Ordinance governing the use of qualified golf carts on City streets and hereby agree to conform with all requirements of the City Ordinance at all times. I have had the opportunity to read said Ordinance and my signature below acknowledges that I will comply with this Ordinance as well as all of the applicable traffic laws of the State of Illinois at all times when operating this golf cart on City Streets.
I, THEREFORE, AGREE TO ASSUME AND TAKE ON MYSELF ALL OF THE RISKS AND RESPONSIBILITIES IN ANYWAY ASSOCIATED WITH THIS ACTIVITY. IN CONSIDERATION OF AND RETURN FOR THE OPPORTUNITY TO OPERATE A GOLF CART ON CITY STREETS, I RELEASE THE CITY (AND THE CITY COUNCIL, EMPLOYEES, AND AGENTS) FROM ANY AND ALL LIABILITY, CLAIMS AND ACTIONS THAT MAY ARISE FROM INJURY OR HARM TO ME OR OTHERS, INCLUDING DEATH, OR FROM DAMAGE TO MY PROPERTY OR PROPERTY OF ANY OTHER IN CONNECTION WITH THIS ACTIVITY. I UNDERSTAND THAT THIS RELEASE ALSO COVERS LIABILITY, CLAIMS AND ACTIONS CAUSED ENTIRELY OR IN PART BY ANY ACTS OR FAILURES TO ACT, INCLUDING BUT NOT LIMITED TO NEGLIGENCE, MISTAKE OR FAILURE TO ENFORCE, SUPERVISE, OR MAINTAIN.
I assure the City that there are no health-related reasons or problems which preclude or restrict my participation in this activity. I further assure the City that I have adequate health and liability insurance necessary to provide for and pay any medical costs or property damage that may directly or indirectly result form my participation in this activity, and I will indemnify and hold the City harmless for any such medical costs or property damage.
I understand that this Release means I am giving up, among other things, rights to sue the City, its City Council, employees, and/or agents for injuries (including death), damages, or losses I may incur or cause. I also understand that this Release binds my heirs, executors, administrators, and assignee, as well as myself.
I HAVE READ THIS ENTIRE RELEASE, I FULLY UNDERSTAND IT, AND I AGREE TO BE LEGALLY BOUND BY IT.
WITNESS: ________________________________
________________________________________ _______________
Applicant’s Signature Date