Required fields are marked with asterisks (*)

Adopt a Road

Please fill out the following application form to participate in an Adopt a Road clean up.

To ensure your application is reviewed in time for your clean up, please submit the application at least seven (7) days prior to your clean up date. After you submit the application, Township staff will contact you after your application has been reviewed to finalize the application and schedule a time for your group representative to pick up the required forms and safety equipment.

Please note it may take up to two (2) business days for staff to review the application and contact your group representative.

Organization Name

Representative Name

Organizer Phone Number

Organizer E-mail Address

Preferred Contact Method

E-mail

Phone

Have you completed an Adopt a Road Agreement?

Yes

Proposed date of clean up and litter disposal?

How many people are planned to participate?