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2. First Name*
3. Last Name*
5. Phone Number*
6. Email Address*
8. Address*
10. City*
11. State*
12. Zip Code*
14. Location of Preferred Hydrant*
    -- Select One --MLK/ Entrance to Capt D'sMLK / Roberta AveMLK / Buena Vista AveMLK / S Mildred AveMLK / Hale AveMLK / Shayne StMLK / Peach StMLK / Schoolhouse StMLK / Stubbs StMLK / S. Main St20 E MLK98 E. MLKMLK / Hazel Ave801 Leonard StMLK / Easy St

    We will try and give you your selected location and if it is already approved for another artist, we will let you know.

15. Please Describe Your Artistic Abilities. Have you participated in a public art project before? If so, what and where?*
17. Incase the preferred hydrant is not available

    1. I will paint any hydrant
19. Use the fire hydrant below to illustrate your proposed artistic design:
21. Design Proposal
    Design Proposal

    Download the pdf for proposal. When ready please upload the completed design. Limit 2 proposals per artist.

22. Upload Attachment*
23. Upload Attachment
25. Fire hydrant Locations
    Map of Fire Hydrants

    Click to view the fire hydrant locations for selecting your preferred hydrant

27. 
29. Title of Work*
31. Electronic Signature Agreement*

    I understand I must paint the sketch I submit to the City of Brooksville

    1. I agree.
33. Electronic Signature*
35. Waiver, Hold Harmless and Indemnity Agreement

    In consideration of the City of Brooksville accepting me as a participant in this program, I understand and agree to the following:

    A. Agreement/General Provisions

    I understand and grant the City of Brooksville, its successors, assigns, and licensees, the perpetual right to photograph, film, use and reproduce, as the City desires, photographs and videotapes taken of myself and/or my children during any activity of this program. I understand that I will not receive any compensation for my participation or my children’s participation in the photographs and videotapes and that the City of Brooksville shall own all right, title, and interest to the photographs and videotapes, including the portions that contain the images and voices of myself and/or children.

    B. Waiver, Hold Harmless and Indemnity

    I fully understand and agree to assume all risks of injury associated as a participant in this program for the City of Brooksville. I understand the City of Brooksville owns the hydrant and reserves the right to repaint for any reason, should the need arise but will avoid doing so to protect and honor the artists work efforts.

    I understand that the City of Brooksville is not responsible for any losses, medical or otherwise, incurred arising out of participation in this program. I hereby waive any and all claims against the City of Brooksville, its elected officials, employees, and/or agents for bodily injury or death arising out of, or in any manner connected with, participation in this program.

    I will defend, indemnify, keep and hold harmless the City of Brooksville, its elected officials, employees, and/or agents from all damages, judgments, expenses (including reasonable attorney fees) suffered because of the injury or the death of any person or persons, or because of damage to property that may arise out of, or as a consequence of my or my family’s participation in this program.

    I certify that I have read and understood the above agreement as the terms under which I will be allowed to participate in this program with the City of Brooksville. This waiver, hold harmless, and indemnity agreement form is effective following signature unless revoked in writing.

37. First Name*

    participant's first and last name - please print

38. Last Name*
40. Address*
42. City*
43. State*
44. Zip Code*
46. 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.
48. Electronic Signature*
49. Date*
    Date

    Date
Leave This Blank:


51. 1. Receive an email copy of this form.
52. Email address

    This field is not part of the form submission.

53. Submit

* indicates a required field