Community Garden Application, Agreement, Waiver and Release Form

The following individual applies for the right to use a garden plot in the Community Action Agency of St. Louis
Owner, Inc. (CAASTLC) Community Garden (Community Garden). If given permission to use a garden plot,
Applicant agrees to the following regulations as to use and represents as follows:
Name(s) __________________________________________________________________________________________
Address: __________________________________________________ E-mail address:_________________________
Telephone Number: _________________________________

Days or Evenings: ______________________________

Community Garden Site Preference:

____________________________________________________________________________________
Applicant would like a garden next to a friend; Name: _____________________________________________________
Applicant has gardened before at (where?); for how long? ___________________________________________________
Please briefly describe Applicants gardening experience. ___________________________________________________
__________________________________________________________________________________________________
Please describe why Applicant wants to participate in the Community Garden. __________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
COMMUNITY GARDEN REGULATIONS
Applicant states and agrees as follows:

1. If I must abandon my plot for any reason, I will notify the garden leadership.
2. I will keep weeds at a minimum and maintain the areas immediately surrounding my plot.
3. If my plot becomes unkempt and overgrown, I understand I will be given one (1) week's notice to
clean and weed it. At that time, it may be re-assigned or tilled in.
4. I will keep trash and litter out of the plot, as well as from adjacent pathways and fences.
5. I will participate in the fall cleanup of the garden.
6. If I plant tall crops, I will assure they will not shade neighboring plots.
7. I will pick only my own crops unless given permission by another plot user.
8. I will not use fertilizers, insecticides or weed repellents that will in any way affect other plots.
9. I agree to volunteer hours toward community gardening efforts.
10. I will not bring pets to the garden other than a seeing assist dog.
11. I understand that neither the garden group nor owners of the land are responsible for my
actions.
12. I am eighteen years of age or older or my parent or legal guardian has signed below.

13. I will use the garden plot assigned to me only in accordance with the Community Garden
Regulations included herein or as may be otherwise announced from time to time.
14. I understand that the Community Garden is located on land owned by ______________
(Owner) and that Owner reserves the right to take full possession of all or any part of the
Community Garden and remove the garden plots, plants, improvements, and other personal
property located on that the land at any time.
15. I also understand that the right to occupy and use a garden plot does not create a real property
tenancy but rather a limited and fully revocable license for such use.
16. I understand and agree there shall be no use of tobacco, alcohol or any illegal substances of
any kind on the premises.
17. I authorize photograph(s) and/or videotaping to be taken of me by CAASTLC solely for the
purposes of promotion, documentation, and/or possible publication in newspaper(s), CAASTLC
report(s), CAASTLC in-house materials, and/or the general media. I understand that neither I
nor anyone else in my family will receive compensation from CAASTLC for such photograph(s)
and/or videotaping. The use of all such photograph(s) and/or videotaping shall be the sole and
exclusive property of CAASTLC.
# of
Members in
Family

Monthly
Income

CAASTLC is federally funded. We seek to collect demographic

information from program participants to help improve the effectiveness
of our programming among low-income residents of St. Louis County.

$ 1,226

$ 1,659

We ask you to please read the table to the right and check the category of
household income that best describes your family.

$ 2,093

$ 2,526

$ 2,959

$ 3,393

More
Than

Less
Than

WAIVER AND RELEASE

In consideration for the license granted to use the Community Garden, I
7
$ 3,826
hereby waive and release CAASTLC and Owner, and their officials,
employees, agents and insurers from any claim, loss or liability for death,
8
$ 4,259
personal injury, or loss or damage to personal property arising out of my
use of the Community Garden unless arising out of CAASTLCs and/or
Owners intentional wrongful acts. I understand that Owner may provide gardeners notice of its intent to re-take
full possession of the Community Garden land but I fully understand and agree that any lack of such that notice
will not prevent Owner from taking possession of its property and removing any garden plots, plants and personal
property located on the Owners land, including my own. In such event, I waive any claim for loss or damage. I
agree to fully indemnify, defend and hold harmless CAASTLC and/or Owner, and their officials, employees, agents
and insurers from any claim or loss or liability made against CAASTLC and/or Owner, and their officials,
employees, agents or insurers by an invitee of mine for death, personal injury, or loss or damage to personal
property arising out of my use of the Community Garden unless arising out of CAASTLCs and/or Owners
intentional wrongful act. I agree that this waiver and release shall be governed by Missouri law.
Dated: ________________, 2015
Signature of Applicant / Gardener: _____________________________
If Applicant is under age eighteen: the parent or legal guardian of the Gardener agrees to the foregoing:
Signature of Parent / Guardian: _________________________

Intake Process Determination if Applicant is an employee or a relative of an employee of

Community Action Agency of St. Louis County, Inc. (CAASTLC)

I, _______________________________________________________, am applying for services through

(print name)
CAASTLC and hereby state that I am ______/am not ______ an employee of CAASTLC or a relative of an
employee of CAASTLC. A relative is defined as any person who is related by blood or marriage (husband, wife,
father, mother, brother, sister, daughter, son, grandfather, grandmother, in-laws or "significant others") to an
employee or whose relationship with the employee is similar to that of persons who are related by blood or
marriage.
If you answered that you are an employee or a relative of an employee please specify if youre an employee or the
type of relative: ___________________________________________________________________________.

Signature: _________________________________________________________________

Date: ____________________________________________________