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2. Date of Clean-Up*
   Date of Clean-Up
4. Group Name*
6. Contact Name*
8. Contact Phone*
9. Contact Email*
11. Requested Street to Adopt*
13. EVENT DETAILS
15. Location(s) Cleaned:
17. Number of Volunteers
    -- Select One --1234567891011121314151617181920212223242526272829303132333435363738394041424344454647484950
18. Number of Hours
    -- Select One --12345678
20. Number of Bags
21. Approximate Weight of Material Collected (lbs)
23. Location of Bags (if Pick-up is required)
25. Materials Collected (check all applicable):

    1. Glass
    2. Aluminum
    3. Other Metals

    1. Wood
    2. Plastics
    3. Cigarette Butts
27. Other (list)
29. Photos of Clean-Up
31. Photo 1
32. Photo 2
33. Photo 3
35. Photo 4
36. Photo 5
37. Photo 6
39. By checking the electronic signature verification box below, I affirm that I am authorized to represent the adopting group listed on this form in regard to cleanup.
41. Signature*

    1. Electronic Signature Verification
43. Name Verification*
44. Date*
    Date
Leave This Blank:


46. 1. Receive an email copy of this form.
47. Email address

    This field is not part of the form submission.

48. Submit

* indicates a required field