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Adopt A Road Application

* Required field! Please fill in the correct information.

Name of Organization:

Contact Person:

Phone:

Email:

Address:

Address to which future information should be mailed (if different from above):

** Location of desired clean-up road or site:

** Date of requested project start up:

(ex: 05/13/2008)

** Schedule of road cleanups (ie. one per month)

** Note:

The Clean Communities Coordinator tries to match every group with their desired location or one nearby. However, if the requested road or site is already adopted, another road or site will be assigned.

How would you describe your organization:

	Civic Group		Community/Neighborhood Group
	Environmental Group		Girl/Boy Scout Troop
	School Group		Athletic Team
	Other, please describe:

Number of total participants:		Kids
		Adults

Additional Comments:

Yes, please include me in any email offers/specials!