Watershed Watch Participant Agreement

Please fill out form, sign and date lines 2 & 5 then turn into Instructor.

Please Print Name: Best Phone

(circle # type) mobile home work

Mailing Address:

City State Zip E-mail:

1.  Equipment checked out to me. Check all that apply.

Phase 1 Equipment / Phase 2 Equipment
Dissolved oxygen kit / White pan (quantity – 1)
pH kit LaMotte HACH (circle one) / D-frame net
Conductivity meter / Tweezers
Thermometer / 325 Ft Reel Line
Waste container / Phase 2 flip cards and bug sheet
White pan (quantity – 1)
Phase 1 flip cards / Recertification Workshop
Replacement chemicals pH DO

Date equipment was loaned to volunteer - I agree to return the equipment that has been loaned to me by the watershed watch program upon my retirement from the program. I agree to care for the equipment that has been loaned to me. If I do not return the equipment upon my retirement from the program I will reimburse the watershed watch program for the replacement costs.

2. Signed ______Date ______

3. Sample Sites Requested

Stream Name / Location and County of Sampling Site

4. Participant Safety Warning & Waiver: I understand and agree that the stream can be a dangerous place and Watershed Watch has no authority to enter private lands. I understand and agree that I am responsible for my own health and safety while participating in Watershed Watch sampling events and activities. I will ask permission before crossing private property. I will be on my guard and exercise due caution when handling chemicals. I agree that I will not hold the Watershed Watch in KY liable for any injury I may incur while volunteering.

5. SIGNED______DATE______

Lead Instructor Verification: This is to verify that the volunteer listed above has completed the modules that I have initialed below:

6. Instructors Name (Print)______Date______

Initials / Phase 1 Modules / Initials / Phase 2 Modules
Gra
Grab Sample Collection / Biological Assessment
Field Chemistry / Habitat Assessment
Program Logistics
Phase 1 Recertification

Note to lead instructor: Please mail the signed form to: Watershed Watch in KY,

c/o Joann Palmer, 300 Sower Blvd., 3rd Floor, Frankfort, KY, 40601.

Office 502-782-7032, Mobile 502-330-1748. Thank you.