Hold_Harmless_Agreement_FY_2015.doc

ACKNOWLEDGMENT OF DANGER; RELEASE AND HOLD HARMLESS AGREEMENT

BARRY M. GOLDWATER RANGE,

CABEZA PRIETA NATIONAL WILDLIFE REFUGE,

AND THE AREA A PORTION OF SONORAN DESERT NATIONAL MONUMENT

(This form is subject to the Privacy Act of 1974)

PERMIT #

C15-

Issuing Agencies: BLM, CPNWR, LAFB, MCAS

AUTHORITY: 10 U.S.C. 5013, 5043 AND 8012; 50 CFR; AND 43 CFR

PRINCIPAL PURPOSE: Indicates certification by an individual or corporation to hold the United States Government, Department of Defense, Department of Interior, and any Barry M. Goldwater Range Lessee or Lessor harmless in consideration of permission granted by the U.S. Government to visit the Barry M. Goldwater Range Complex (BMGR), Area A portion of the Sonoran Desert National Monument (SDNM), and Cabeza Prieta National Wildlife Refuge (CPNWR).

ROUTINE USES: Used to gain access to the BMGR, Area A portion of SDNM, and/or the CPNWR.

DISCLOSURE IS VOLUNTARY: Failure to provide this information would result in an individual or corporation being denied access to the BMGR/CPNWR/Area A portion of SDNM.

TERM OF PERMIT: This permit is valid from July 1 through June 30 for the CPNWR, Area A portion of SDNM, and the BMGR East and West. This permit does not grant you access to TACTICAL, MANNED, or Light Amplification by Stimulated Emission of Radiation (LASER) ranges. Some areas may be periodically designated as closed due to military operations.

PLEASE READ AND INITIAL EACH BLANK

________ 1. The BMGR/CPNWR/Area A portion of SDNM contains the danger of property damage and permanent, painful, disabling, and disfiguring injury or death due to high explosive detonations from falling objects such as aircraft, aerial targets, live ammunition, missiles, bombs, etc. There are also physical injury and health dangers from ground and aerial LASER and other electromagnetic emissions.

2. The BMGR/CPNWR/Area A portion of SDNM contains the danger of property damage and permanent, painful, disabling, and disfiguring injury or death due to the presence of expended, but still live, bombs, rockets, cannon rounds, flares, and other types of warheads. Unexploded munitions may be encountered anywhere within the BMGR/CPNWR/Area A portion of SDNM: lying on the ground partially or completely buried. These munitions can still explode though they may have lain in the desert for decades. I have been instructed NOT to approach or disturb any military equipment or ordnance discovered on the BMGR, Area A portion of SDNM, or CPNWR.

3. The BMGR/CPNWR/Area A portion of SDNM contains the danger of injury or death from the presence of old mine shafts and other openings or weaknesses in the earth, as well as other natural and/or man-made conditions which are too numerous to recite herein.

4. The BMGR/CPNWR/Area A portion of SDNM cannot feasibly be marked to warn of the location and nature of each danger. Further, there are few road signs or other navigational aids to assist visitors.

5. The BMGR/CPNWR/Area A portion of SDNM occupies one of the most extreme environments in North America. I have been advised to guard against the dangers presented by the BMGR/CPNWR/Area A portion of SDNM's rugged landscape, high temperatures, remoteness, and other threats such as venomous reptiles. The BMGR/CPNWR/Area A portion of SDNM contains no sources of safe drinking water. I have been advised to pack sufficient water, food, and first aid supplies with me at all times.

6. The BMGR/CPNWR/Area A portion of SDNM has no services. If I get lost, if my vehicle breaks down, or in the case of any emergency, I AM ON MY OWN. There are no regular patrols of the BMGR/CPNWR/Area A portion of SDNM. I certify that I have informed friends or family of my anticipated route and time of return from the BMGR/CPNWR/Area A portion of SDNM. I will bear the full cost of all search and rescue activities resulting from my actions on the BMGR/CPNWR/Area A portion of SDNM.

7. I have been warned that I am responsible for knowing and abiding by all federal, military, and state laws and regulations pertaining to use of BMGR/CPNWR/Area A portion of SDNM.

8. I recognize that the Cabeza Prieta is a National Wildlife Refuge and a designated wilderness area with significant differences in use. I have read and understand the applicable rules and regulations.

9. All public access and use of the BMGR/CPNWR/Area A portion of SDNM may only be authorized by permit and is accompanied by significant limitations. All individuals or entities that apply for an access permit, regardless of their intended use, will be subject to comply with all Federal, State, and local laws, regulations, and policies in force over the BMGR/CPNWR/Area A portion of SDNM.

10. Any entity, other than a private individual, is required to obtain a Special Use Permit for authorization to gain access and use to the BMGR/CPNWR/Area A portion of SDNM. Special Use Permits may only be issued by the agency responsible for the affected land.

11. Anyone granted a range permit for access and use who violates the parameters of their permit is subject to judicial penalties to include a fine, civil action, and debarment.

12. When on the BMGR/CPNWR/Area A portion of SDNM, I will possess a valid permit at all times and present it upon request to any authorized Department of the Air Force civilian, Border Patrol agent, law enforcement officer or U.S. military personnel. Any person without a valid permit may be fined and/or barred from the BMGR/CPNWR/Area A portion of SDNM.

13. I am aware there is the possibility of encountering undocumented aliens while on the Range. I may be asked to produce my permit and/or additional identification by Border Patrol agents while accessing the BMGR/CPNWR/Area A.

14. I UNDERSTAND I MUST CALL PRIOR TO EACH VISIT TO RECORD SPECIFIC TRIP INFORMATION AND TO RECEIVE ANY INFORMATION ABOUT WILDLAND FIRES, ROAD CLOSURES, OR OTHER PERTINENT INFORMATION. If visiting BMGR-West, I will call 928/269-7150 or Yuma After-Hours to 928-343-4393. If visiting CPNWR, I will sign in at the refuge entrance to record my visit. If visiting the SDNM or BMGR-East, I will call 623-856-5241 or 928-683-6241.

Upon my own initiative, therefore, and at my own risk, I accept permission to enter this area and in consideration of such permission do, for myself, my spouse, my children, my heirs, personal representatives, and assignees of the same, remise, release, and forever discharge as well as agree to indemnify and hold harmless the United States Government, any lessee there from, any individual officer, agent, employee, or director thereof from any claim of liability for injury, death, or property damage arising out of my usage of or presence upon said Barry M. Goldwater Range in accordance with permission to enter thereon.

I further affirm that I will never prosecute or assist in prosecuting any civil action against the United States Government, the U.S. Marine Corps, U.S. Air Force, or U.S. Department of Interior, or any of their agents, employees, service members, contractors, or lessees for claim or liability arising from my entry to the BMGR/CPNWR/Area A portion of SDNM.

Please fill in the following:

Name (Print or Type)

Signature

Date

Street Address

City/State/Zip Code

Home Telephone

Work Telephone

Cell Phone Drivers License Number and State of Issuance:

Vehicle(s) Description(s): (NOTE: ALL vehicles MUST be registered, Arizona Highway Legal, AND Insured.)

Vehicle #1: Year Style Make

Color License # State

4WD

Yes No

Vehicle #2: Year Style Make

Color License # State

4WD

Yes No

Each adult individual (18 years or older) in the group must complete, sign, and submit a separate HOLD HARMLESS AGREEMENT AND PERMIT APPLICATION.

I, , have received a map with regulations and procedures for legal access to the BMGR, Area A portion of SDNM, and the CPNWR. I understand that non-compliance with any state and federal laws and with BMGR/CPNWR/Area A portion of SDNM rules and regulations, by me or anyone accompanying me, is a violation of this permit. My access may be revoked or suspended for violations or conduct inconsistent to the management goals of the BMGR/CPNWR/Area A portion of SDNM. I CERTIFY THAT BEFORE SIGNING BELOW, I RECEIVED, READ, AND UNDERSTAND THE HOLD HARMLESS AGREEMENT, THE BMGR/CPNWR/Area A portion of SDNM REGULATIONS, AND MAP.

Signature

Date