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2. RAT CONTROL PROGRAM PARTICIPANT WAIVER OF LIABILITY AND HOLD HARMLESS AGREEMENT

   For inquiries or to provide updated information please send an email with your address as the subject line to publicworks@lwd.org. If you submitted this form in the last 60 days, there is no need for further submissions. Waivers must be submitted by noon Wednesday to be on the next-day treatment list. 

4. Have you submitted a Rat Control Waiver within the last 60 days? *

   1. Yes
   2. No
6. Name*
7. Email Address*
9. Address*
11. City
13. Phone Number*
15. Please provide a description of the problem*
17. If you would like to submit a photo of a suspected rat burrow please do so below:
19. Do you have a dog? *

    1. Yes
    2. No
21. In consideration of the undersigned,
23. Please fill in your name *

    [name of organization or individual requesting Rat Control Services] 

25.  being given the opportunity to observe and/or take part in the Village’s Rat Control Program (“Event”) in any manner whatsoever, presented, sponsored, operated or  provided by the Village of Lincolnwood the undersigned hereby acknowledges that it/he/she is participating voluntarily and recognizes, acknowledges and assumes any and all risk of injury (including death) and waives and relinquishes any and all claims it/he/she may have arising out of, connected with, or in any way associated with observing or taking part in the  Event. The undersigned does hereby fully release and discharge the Village of Lincolnwood, its officers, employees and agents from any and all claims from injuries, including death, damage, or loss which the undersigned may have or which may occur on account of participation in the Event.

    To the fullest extent permitted by law, the undersigned hereby indemnifies, defends, and holds harmless the Village of Lincolnwood and its officers, employees and agents from and against any and all claims, damages, liability or claim of liability, loss or expense including, but not limited to, liability expense and claims for:  bodily injury, death, personal injury, or property damage and  including defense costs and legal fees for claims of whatever character, nature and kind, whether directly or indirectly arising from or connected with the undersigned’s participating in the Event.  

    I have requested employees of the Village of Lincolnwood and/or its contractor, to come onto my property to treat for rat activity. I understand that rodenticide may be used as treatment, which is poisonous to children, pets, and wildlife. To receive this service, I agree to follow the recommendations provided by the Village including removing animal feces, not feeding pets or wildlife outside, and repairing refuse carts to prevent animal entry/feeding. I agree to release the Village from liability and to indemnify contractors and employees harmless from any claims for property damage, personal injury, or illness as a result of the application of rodenticide. Rats that have expired should be double-bagged and discarded in a refuse cart.

    This Waiver of Liability and Hold Harmless Agreement is governed by the laws of the State of Illinois. The invalidity or unenforceability of any of the provisions hereof will not affect the validity or enforceability of the remainder of this Agreement.

27. If you agree with this waiver please check the box below*

    1. Yes, I agree to the terms of the Village of Lincolnwood's Rat Control Program Participant Waiver of Liability and Hold Harmless Agreement
29. By signing below, the participant has read and understands the waiver as described above.*

    Signature of Participant 

31. I would like to receive the Village's E-Newsletters

    1. Yes
    2. No

    The Village of Lincolnwood provides biweekly digital newsletters to keep residents up-to-date on the latest programs, activities, and initiatives within the community. Throughout the Spring and Summer months, we also offer a weekly newsletter to ensure residents stay informed about ongoing construction projects and developments within the Village. 

Leave This Blank:


33. 1. Receive an email copy of this form.
34. Email address

    This field is not part of the form submission.

35. Submit

* indicates a required field