Termination of the Program. The Adopt-A-Road Program may at any time and for any reason be terminated at the discretion of the sponsors. FORMS TO RETURN ADOPT A ROAD PROGRAM AGREEMENT SCHEDULE OF CLEANUPS INDIVIDUAL REGISTRATION FORM POST-CLEANUP FORM Please note dates and instructions for sending back the following pages in order to participate in the Adopt-a-Road Program. These pages are provided for your convenience and ease of record-keeping. E-mail: xxxxxxxxxx@xxxxxxxxxx.xxx Mail: Gwinnett Clean & Beautiful Services, Inc. 0000 Xxxxxxxxx Xxxxxxxxx Xxxxxx, XX 00000 Fax: 000-000-0000 ADOPT-A-ROAD PROGRAM AGREEMENT Please e-mail, mail, or fax completed form to Gwinnett Clean & Beautiful 0000 Xxxxxxxxx Xxxxxxxxx, Xxxxxx, XX, 00000, Fax: (000) 000-0000 On this date of , 20 , The Gwinnett County Department of Transportation and Gwinnett Clean & Beautiful Services (herein after referred to as the “Sponsors”) and (herein after referred to as the “Group”) recognize the need and the desirability of litter-free and visually-improved roadways. The Adopt-A-Road Program has been established for Gwinnett County community and civic organizations, citizens and private businesses to contribute toward the effort of maintaining cleaner and more beautiful roads. An Individual Registration Form must be completed prior to a cleanup. As indicated by their signatures on the Individual Registration Form, the individual participants of the Group are aware of the hazardous nature of the work which is to be performed and have agreed to follow the Sponsors’ safety guidelines and instructions. All participants have agreed to not hold the Sponsors responsible for any injuries they may suffer or damages that they may cause or suffer as a result of participation in the program. The Sponsors recognize the Group as the adopting organization for (roadway), from (crossroad that begins your chosen road section) to (crossroad road that ends your chosen road section). The Group commits to pick up litter and remove illegal signs at least 4 times a year (or more if necessary) along its section of roadway, and promote a better environment in the community for a period beginning (same date as listed above) and ending (one year later). Authorized Group Representative E-mail Address ( ) ( ) ( ) Home Phone Work Phone Fax Number Street Address City Zip Code ***FOR NEW GROUPS: Road sign name plates only have room for three lines of approximately 8- 10 characters (including spaces). Please write how you would like your sign name to read, using abbreviations if need be. Group Name on Sign: Line 1 Line 2 Line 3 Schedule of Cleanups Please fax or mail completed form to Gwinnett Clean & Beautiful 0000 Xxxxxxxxx Xxxxxxxxx, Xxxxxx, XX, 00000, Fax: (000) 000-0000 Please submit dates for your cleanups. These dates are used for planning purposes. By submitting these dates to us, you are not committing your group to definitely cleaning up on that date. If you’d like to change your cleanup date, simply notify our office at least 5 business days in advance by phone (000) 000-0000, fax (000) 000-0000 or email xxxxxxxxxx@xxxxxxxxxx.xxx. Group: Contact: Phone: First cleanup date: Second cleanup date: Third cleanup date: Fourth cleanup date: Optional cleanup date: Optional cleanup date: Post Cleanup Form Please submit within 30 days after each cleanup to: Submit online via our website at xxx.xxxxxxxxxx.xxx/xxxxxxxxx/xxxxx-x-xxxx-xxxx-xxxxxxx/ or Fax: 770/000-0000, Email: xxxxxxxxxx@xxxxxxxxxx.xxx Mail: 0000 Xxxxxxxxx Xxxxxxxxx, Xxxxxx, XX 00000 CONTACT INFORMATION Group Name: Contact name: Phone: ( ) Email address: Mailing address: City Zip CLEANUP DETAILS Date of Cleanup: Location of Cleanup: # of bags of garbage you collected: # of illegal signs you collected: Approximate weight of total litter and garbage collected (20lbs/bag plus approximate weight of other large items): # of volunteers: # of hours worked: Do you need the Department of Transportation to pick up the bags? Yes No If yes, you must also be able to answer yes to the following questions: Are the bags within the right-of-way (area between the utility pole and curb)? Is the trash located next to an intersection and clearly visible? Are there any other items other than bags that need to be removed? If yes, please describe the type and amount: Intersection where the trash is located for pick-up: Comments or suggestions: Individual Registration Form Please email, fax, or mail completed form to Gwinnett Clean & Beautiful 0000 Xxxxxxxxx Xxxxxxxxx, Xxxxxx, XX, 00000, Fax: (000) 000-0000 The following persons will participate in one or more litter pick-ups. By their signatures they agree to abide by the Sponsors’ guidelines and to not hold the Sponsors responsible for any injuries they may suffer or damages that they may cause or suffer as a result of participation in the Adopt-A-Road Program. No one under the age of 12 will be allowed to participate in the Adopt-a-Road program. Note: Participants under the age of 18 will require a signature from a parent or guardian on the Youth Registration Form and do not need to sign below. Group Name: Phone: ( )
Appears in 1 contract
Samples: Program Agreement
Termination of the Program. The Adopt-A-Road Program may at any time and for any reason be terminated at the discretion of the sponsors. RESOURCES OBTAINED FROM GWINNETT CLEAN AND BEAUTIFUL SERVICES, INC. FORMS TO RETURN ADOPT A ROAD PROGRAM AGREEMENT SCHEDULE OF CLEANUPS INDIVIDUAL REGISTRATION FORM POST-CLEANUP FORM Please note dates and instructions for sending back the following pages in order to participate in the Adopt-a-Road Program. These pages are provided for your convenience and ease of record-keeping. E-mail: xxxxxxxxxx@xxxxxxxxxx.xxx x.xxxxxx@xxxxxxxxxxx-xx.xxx Mail: Gwinnett Clean & Beautiful ServicesXxxxx County Sheriff’s Xxxxxx 000 XX XXX 00 XXXXX Xxxxxxxxxx, Inc. 0000 Xxxxxxxxx Xxxxxxxxx Xxxxxx, XX Xxxxxxx 00000 Fax: 000-000-0000 ADOPT-A-ROAD PROGRAM AGREEMENT Please e-mail, mail, or fax completed form to Gwinnett Clean & Beautiful 0000 Xxxxxxxxx XxxxxxxxxXxxxx County Sheriff’s Xxxxxx 000 XX Xxx 00 Xxxxx Xxxxxxxxxx, Xxxxxx, XX, 00000, Xxxxxxx 00000 Fax: (000) -000-0000 On this date of , 20 , The Gwinnett Xxxxx County Department of Transportation and Gwinnett Clean & Beautiful Services Sheriff’s Office (herein after referred to as the “Sponsors”) and (herein after referred to as the “Group”) recognize the need and the desirability of litter-free and visually-improved roadways. The Adopt-A-Road Program has been established for Gwinnett Xxxxx County community and civic organizations, citizens and private businesses to contribute toward the effort of maintaining cleaner and more beautiful roads. An Individual Registration Form must be completed prior to a cleanup. As indicated by their signatures on the Individual Registration Form, the individual participants of the Group are aware of the hazardous nature of the work which is to be performed and have agreed to follow the Sponsors’ safety guidelines and instructions. All participants have agreed to not hold the Sponsors responsible for any injuries they may suffer or damages that they may cause or suffer as a result of participation in the program. The Sponsors recognize the Group as the adopting organization for (roadway), from (crossroad that begins your chosen road section) to (crossroad road that ends your chosen road section). The Group commits to pick up litter and remove illegal signs at least 4 3 times a year (or more if necessary) along its section of roadway, and promote a better environment in the community for a period beginning (same date as listed above) and ending (one year later). Authorized Group Representative E-mail Address ( ) ( ) ( ) Home Primary Phone Work # Secondary Phone # Fax Number Street Address City Zip Code ***FOR NEW GROUPS: Road sign name plates only have room for three lines of approximately 8- 10 characters (including spaces). Please write how you would like your sign name to read, using abbreviations if need be. Group Name on Sign: Line 1 Line 2 Line 3 Schedule of Cleanups Please e-mail, mail, or fax or mail completed form to Gwinnett Clean & Beautiful 0000 Xxxxxxxxx XxxxxxxxxXxxxx County Sheriff’s Xxxxxx 000 XX Xxx 00 Xxxxx Xxxxxxxxxx, Xxxxxx, XX, 00000, Xxxxxxx 00000 Fax: (000) -000-0000 Please submit dates for your cleanups. These dates are used for planning purposes. By submitting these dates to us, you are not committing your group to definitely cleaning up on that date. If you’d like to change your cleanup date, simply notify our office at least 5 business days in advance by phone (000) 000-0000, fax (000) 000-0000 or email xxxxxxxxxx@xxxxxxxxxx.xxxx.xxxxxx@xxxxxxxxxxx-xx.xxx. Group: Contact: Phone: First cleanup date: Second cleanup date: Third cleanup date: Fourth Optional cleanup date: Optional cleanup date: Optional cleanup date: Post Cleanup Form Please submit within 30 days after each cleanup tocleanup: Submit online via our website at xxx.xxxxxxxxxx.xxx/xxxxxxxxx/xxxxx-x-xxxx-xxxx-xxxxxxx/ e-mail, mail, or fax completed form to Xxxxx County Sheriff’s Xxxxxx000 XX Xxx 00 Xxxxx Xxxxxxxxxx, Xxxxxxx 00000 Fax: 770/000000-0000, Email: xxxxxxxxxx@xxxxxxxxxx.xxx Mail: 000-0000 Xxxxxxxxx Xxxxxxxxx, Xxxxxx, XX 00000 CONTACT INFORMATION Group Name: Contact name: Phone: ( ) Email address: Mailing address: City Zip CLEANUP DETAILS Date of Cleanup: Location of Cleanup: # of bags of garbage you collected: # of illegal signs you collected: Approximate weight of total litter and garbage collected (20lbs/bag plus approximate weight of other large items): # of volunteers: # of hours worked: Do you need the Department of Transportation XXXXX COUNTY ROAD DEPARTMENT to pick up the bags? Yes Yes/No If yes, you must also be able to answer yes to the following questions: Are the bags within the right-of-way (area between the utility pole and curb)? Is the trash located next to an intersection and clearly visible? Are there any other items other than bags that need to be removed? If yes, please describe the type and amount: Intersection where the trash is located for pick-up: Comments or suggestions: Individual Registration Form Please emaile-mail, faxmail, or mail fax completed form to Gwinnett Clean & Beautiful 0000 Xxxxxxxxx XxxxxxxxxXxxxx County Sheriff’s Xxxxxx000 XX Xxx 00 Xxxxx Xxxxxxxxxx, Xxxxxx, XX, 00000, Xxxxxxx 00000 Fax: (000) 000-0000 The following persons will participate in one or more litter pick000-ups. By their signatures they agree to abide by the Sponsors’ guidelines and to not hold the Sponsors responsible for any injuries they may suffer or damages that they may cause or suffer as a result of participation in the Adopt-A-Road Program. No one under the age of 12 will be allowed to participate in the Adopt-a-Road program. Note: Participants under the age of 18 will require a signature from a parent or guardian on the Youth Registration Form and do not need to sign below. Group Name: Phone: ( )0000
Appears in 1 contract
Samples: Program Agreement
Termination of the Program. The Adopt-A-Road Program may at any time and for any reason be terminated at the discretion of the sponsors. RESOURCES OBTAINED FROM GWINNETT CLEAN AND BEAUTIFUL SERVICES, INC. FORMS TO RETURN • ADOPT A ROAD PROGRAM AGREEMENT • SCHEDULE OF CLEANUPS • INDIVIDUAL REGISTRATION FORM • POST-CLEANUP FORM Please note dates and instructions for sending back the following pages in order to participate in the Adopt-a-Road Program. These pages are provided for your convenience and ease of record-keeping. E-mail: xxxxxxxxxx@xxxxxxxxxx.xxx x.xxxxxx@xxxxxxxxxxx-xx.xxx Mail: Gwinnett Clean & Beautiful ServicesXxxxx County Sheriff’s Xxxxxx 000 XX XXX 00 XXXXX Xxxxxxxxxx, Inc. 0000 Xxxxxxxxx Xxxxxxxxx Xxxxxx, XX Xxxxxxx 00000 Fax: 000-000-0000 ADOPT-A-ROAD PROGRAM AGREEMENT Please e-mail, mail, or fax completed form to Gwinnett Clean & Beautiful 0000 Xxxxxxxxx XxxxxxxxxXxxxx County Sheriff’s Xxxxxx 000 XX Xxx 00 Xxxxx Xxxxxxxxxx, Xxxxxx, XX, 00000, Xxxxxxx 00000 Fax: (000) -000-0000 On this date of , 20 , The Gwinnett Xxxxx County Department of Transportation and Gwinnett Clean & Beautiful Services Sheriff’s Office (herein after referred to as the “Sponsors”) and (herein after referred to as the “Group”) recognize the need and the desirability of litter-free and visually-improved roadways. The Adopt-A-Road Program has been established for Gwinnett Xxxxx County community and civic organizations, citizens and private businesses to contribute toward the effort of maintaining cleaner and more beautiful roads. An Individual Registration Form must be completed prior to a cleanup. As indicated by their signatures on the Individual Registration Form, the individual participants of the Group are aware of the hazardous nature of the work which is to be performed and have agreed to follow the Sponsors’ safety guidelines and instructions. All participants have agreed to not hold the Sponsors responsible for any injuries they may suffer or damages that they may cause or suffer as a result of participation in the program. The Sponsors recognize the Group as the adopting organization for (roadway), from (crossroad that begins your chosen road section) to (crossroad road that ends your chosen road section). The Group commits to pick up litter and remove illegal signs at least 4 3 times a year (or more if necessary) along its section of roadway, and promote a better environment in the community for a period beginning (same date as listed above) and ending (one year later). Authorized Group Representative E-mail Address ( ) ( ) ( ) Home Primary Phone Work # Secondary Phone # Fax Number Street Address City Zip Code ***FOR NEW GROUPS: Road sign name plates only have room for three lines of approximately 8- 10 characters (including spaces). Please write how you would like your sign name to read, using abbreviations if need be. Group Name on Sign: Line 1 Line 2 Line 3 Schedule of Cleanups Please e-mail, mail, or fax or mail completed form to Gwinnett Clean & Beautiful 0000 Xxxxxxxxx XxxxxxxxxXxxxx County Sheriff’s Xxxxxx 000 XX Xxx 00 Xxxxx Xxxxxxxxxx, Xxxxxx, XX, 00000, Xxxxxxx 00000 Fax: (000) -000-0000 Please submit dates for your cleanups. These dates are used for planning purposes. By submitting these dates to us, you are not committing your group to definitely cleaning up on that date. If you’d like to change your cleanup date, simply notify our office at least 5 business days in advance by phone (000) 000-0000, fax (000) 000-0000 or email xxxxxxxxxx@xxxxxxxxxx.xxxx.xxxxxx@xxxxxxxxxxx-xx.xxx. Group: Contact: Phone: First cleanup date: Second cleanup date: Third cleanup date: Fourth Optional cleanup date: Optional cleanup date: Optional cleanup date: Post Cleanup Form Please submit within 30 days after each cleanup tocleanup: Submit online via our website at xxx.xxxxxxxxxx.xxx/xxxxxxxxx/xxxxx-x-xxxx-xxxx-xxxxxxx/ e-mail, mail, or fax completed form to Xxxxx County Sheriff’s Xxxxxx000 XX Xxx 00 Xxxxx Xxxxxxxxxx, Xxxxxxx 00000 Fax: 770/000000-0000, Email: xxxxxxxxxx@xxxxxxxxxx.xxx Mail: 000-0000 Xxxxxxxxx Xxxxxxxxx, Xxxxxx, XX 00000 CONTACT INFORMATION Group Name: Contact name: Phone: ( ) Email address: Mailing address: City Zip CLEANUP DETAILS Date of Cleanup: Location of Cleanup: # of bags of garbage you collected: # of illegal signs you collected: Approximate weight of total litter and garbage collected (20lbs/bag plus approximate weight of other large items): # of volunteers: # of hours worked: Do you need the Department of Transportation XXXXX COUNTY ROAD DEPARTMENT to pick up the bags? Yes Yes/No If yes, you must also be able to answer yes to the following questions: • Are the bags within the right-of-way (area between the utility pole and curb)? • Is the trash located next to an intersection and clearly visible? Are there any other items other than bags that need to be removed? If yes, please describe the type and amount: Intersection where the trash is located for pick-up: Comments or suggestions: Individual Registration Form Please emaile-mail, faxmail, or mail fax completed form to Gwinnett Clean & Beautiful 0000 Xxxxxxxxx XxxxxxxxxXxxxx County Sheriff’s Xxxxxx000 XX Xxx 00 Xxxxx Xxxxxxxxxx, Xxxxxx, XX, 00000, Xxxxxxx 00000 Fax: (000) 000-0000 The following persons will participate in one or more litter pick000-ups. By their signatures they agree to abide by the Sponsors’ guidelines and to not hold the Sponsors responsible for any injuries they may suffer or damages that they may cause or suffer as a result of participation in the Adopt-A-Road Program. No one under the age of 12 will be allowed to participate in the Adopt-a-Road program. Note: Participants under the age of 18 will require a signature from a parent or guardian on the Youth Registration Form and do not need to sign below. Group Name: Phone: ( )0000
Appears in 1 contract
Samples: Program Agreement
Termination of the Program. The Adopt-A-Road Program may at any time and for any reason be terminated at the discretion of the sponsors. FORMS TO RETURN ADOPT A ROAD PROGRAM AGREEMENT SCHEDULE OF CLEANUPS INDIVIDUAL REGISTRATION FORM POST-CLEANUP FORM Please note dates and instructions for sending back the following pages in order to participate in the Adopt-a-Road Program. These pages are provided for your convenience and ease of record-keeping. E-mail: xxxxxxxxxx@xxxxxxxxxx.xxx Mail: Gwinnett Clean & Beautiful Services, Inc. 0000 Xxxxxxxxx Xxxxxxxxx Xxxxxx, XX 00000 Fax: 000-000-0000 ADOPT-A-ROAD PROGRAM AGREEMENT Please e-mail, mail, or fax completed form to Gwinnett Clean & Beautiful 0000 Xxxxxxxxx Xxxxxxxxx, Xxxxxx, XX, 00000, Fax: (000) 000-0000 On this date of , 20 , The Gwinnett County Department of Transportation and Gwinnett Clean & Beautiful Services (herein after referred to as the “Sponsors”) and _______________________________________(herein after referred to as the “Group”) recognize the need and the desirability of litter-free and visually-improved roadways. The Adopt-A-Road Program has been established for Gwinnett County community and civic organizations, citizens and private businesses to contribute toward the effort of maintaining cleaner and more beautiful roads. An Individual Registration Form must be completed prior to a cleanup. As indicated by their signatures on the Individual Registration Form, the individual participants of the Group are aware of the hazardous nature of the work which is to be performed and have agreed to follow the Sponsors’ safety guidelines and instructions. All participants have agreed to not hold the Sponsors responsible for any injuries they may suffer or damages that they may cause or suffer as a result of participation in the program. The Sponsors recognize the Group as the adopting organization for ____________________________________________________(roadway), from ___________________________(crossroad that begins your chosen road section) to _______________________________(crossroad road that ends your chosen road section). The Group commits to pick up litter and remove illegal signs at least 4 times a year (or more if necessary) along its section of roadway, and promote a better environment in the community for a period beginning __________________________ (same date as listed above) and ending _________________(one year later). ________________________________________ Authorized Group Representative E-mail Address ( ) )__________________ ( ) )__________________ ( ) )_________________ Home Phone Work Phone Fax Number ____________________________________________________________________________ Street Address _______________________ ________________ City Zip Code ***FOR NEW GROUPS: Road sign name plates only have room for three lines of approximately 8- 8-10 characters (including spaces). Please write how you would like your sign name to read, using abbreviations if need be. Group Name on Sign: _________________ ____________________ ___________________ Line 1 Line 2 Line 3 Schedule of Cleanups Please fax or mail completed form to Gwinnett Clean & Beautiful 0000 Xxxxxxxxx Xxxxxxxxx, Xxxxxx, XX, 00000, Fax: (000) 000-0000 Please submit dates for your cleanups. These dates are used for planning purposes. By submitting these dates to us, you are not committing your group to definitely cleaning up on that date. If you’d like to change your cleanup date, simply notify our office at least 5 business days in advance by phone (000) 000-0000, fax (000) 000-0000 or email xxxxxxxxxx@xxxxxxxxxx.xxx. Group: _____________________________________________________________ Contact: _____________________________ Phone: ______________________________ First cleanup date: ___________________________________ Second cleanup date: _________________________________ Third cleanup date: :____________________________________ Fourth cleanup date: __________________________________ Optional cleanup date: _________________________________ Optional cleanup date: Post _________________________________ P ost Cleanup Form Please submit within 30 days after each cleanup to: Submit online via our website at xxx.xxxxxxxxxx.xxx/xxxxxxxxx/xxxxx-x-xxxx-xxxx-xxxxxxx/ or Fax: 770/000-0000, Email: xxxxxxxxxx@xxxxxxxxxx.xxx Mail: 0000 Xxxxxxxxx Xxxxxxxxx, Xxxxxx, XX 00000 CONTACT INFORMATION Group Name: _________________________________________________________ Contact name: __________________________ Phone: ( ) (_____)________________ Email address: _______________________________________ Mailing address: ______________________________________________________ City Zip ______________________________ Zip_____________ CLEANUP DETAILS Date of Cleanup: _______________ Location of Cleanup: _______________________ # of bags of garbage you collected: _______ # of illegal signs you collected: ________ Approximate weight of total litter and garbage collected (20lbs/bag plus approximate weight of other large items): _______ # of volunteers: _______ # of hours worked: _______ Do you need the Department of Transportation to pick up the bags? Yes No If yes, you must also be able to answer yes to the following questions: Are the bags within the right-of-way (area between the utility pole and curb)? Is the trash located next to an intersection and clearly visible? Are there any other items other than bags that need to be removed? If yes, please describe the type and amount: ____________________________________________ Intersection where the trash is located for pick-up: _____________________________________________________________________ Comments or suggestions: _______________________________________________ _____________________________________________________________________ Individual Registration Form Please email, fax, or mail completed form to Gwinnett Clean & Beautiful 0000 Xxxxxxxxx Xxxxxxxxx, Xxxxxx, XX, 00000, Fax: (000) 000-0000 The following persons will participate in one or more litter pick-ups. By their signatures they agree to abide by the Sponsors’ guidelines and to not hold the Sponsors responsible for any injuries they may suffer or damages that they may cause or suffer as a result of participation in the Adopt-A-Road Program. No one under the age of 12 will be allowed to participate in the Adopt-a-Road program. Note: Participants under the age of 18 will require a signature from a parent or guardian on the Youth Registration Form and do not need to sign below. Group Name: _____________________________ Phone: ( (____)________________ Contact Person: __________________________ Email: ______________________ Name:________________________________________________Date:____________ Name:________________________________________________Date:____________ Name:________________________________________________Date:____________ Name:________________________________________________Date:____________ Name:________________________________________________Date:____________ Name:________________________________________________Date:____________ Name:________________________________________________Date:____________ Name:________________________________________________Date:____________ Name:________________________________________________Date:____________ Name:________________________________________________Date:____________ Name:________________________________________________Date:____________ Name:________________________________________________Date:____________ Name:________________________________________________Date:____________ Name:________________________________________________Date:____________ Youth Individual Registration Form (for participants age 12-17 years old) I, ________________________________(please print parent/guardian’s name), allow ____________________________________(please print participant’s name) to participate in the Gwinnett County Adopt-a-Road program. We have both read the program rules and regulations and agree to abide by the Sponsors’ guidelines. I agree to not hold the Sponsors responsible for any injuries that the aforementioned participant may suffer or damages that they may cause or suffer as a result of the Adopt-a-Road program. Name of Group: ___________________________________________________________ ___________________________________ __________________________________ (signature) (Date)
Appears in 1 contract
Samples: Program Agreement
Termination of the Program. The Adopt-A-Road Program may at any time and for any reason be terminated at the discretion of the sponsors. FORMS TO RETURN ADOPT A ROAD PROGRAM AGREEMENT SCHEDULE OF CLEANUPS INDIVIDUAL REGISTRATION FORM VOLUNTEER GWINNETT WAIVERS POST-CLEANUP FORM Please note dates and instructions for sending back the following pages in order to participate in the Adopt-a-Road Program. These pages are provided for your convenience and ease of record-keeping. E-mail: xxxxxxxxxx@xxxxxxxxxx.xxx Mail: Gwinnett Clean & Beautiful Services, Inc. 0000 Xxxxxxxxx Xxxxxxxxx 000 Xxxx Xxxxxx Xxxxxx, XX 00000 Ste. 225 Lawrenceville, GA 30046 Fax: 000-000-0000 ADOPT-A-ROAD PROGRAM AGREEMENT Please e-mail, mail, or fax completed form to Gwinnett Clean & Beautiful 0000 Xxxxxxxxx Xxxxxxxxx000 X. Xxxxxx St., XxxxxxSte. 225, XXLawrenceville, 00000GA, 30046, Fax: (000) 000-0000 On this date of , 20 , The Gwinnett County Department of Transportation and Gwinnett Clean & Beautiful Services (herein after referred to as the “Sponsors”) and _______________________________________ (herein after referred to as the “Group”) recognize the need and the desirability of litter-free and visually-improved roadways. The Adopt-A-Road Program has been established for Gwinnett County community and civic organizations, citizens and private businesses to contribute toward the effort of maintaining cleaner and more beautiful roads. An Individual Registration Form must be completed prior to a cleanup. As indicated by their signatures on the Individual Registration Form, the individual participants of the Group are aware of the hazardous nature of the work which is to be performed and have agreed to follow the Sponsors’ safety guidelines and instructions. All participants have agreed to not hold the Sponsors responsible for any injuries they may suffer or damages that they may cause or suffer as a result of participation in the program. The Sponsors recognize the Group as the adopting organization for ____________________________________________________ (roadway), from ___________________________(crossroad that begins your chosen road section) to _______________________________(crossroad road that ends your chosen road section). The Group commits to pick up litter and remove illegal signs at least 4 times a year (or more if necessary) along its section of roadway, and promote a better environment in the community for a period beginning __________________________ (same date as listed above) and ending _________________(one year later). ________________________________________ Authorized Group Representative E-mail Address ( ) )__________________ ( ) )__________________ ( ) Home )_________________ Primary Phone Work # Secondary Phone # Fax Number ____________________________________________________________________________ Street Address _______________________ ________________ City Zip Code ***FOR NEW GROUPS: Road sign name plates only have room for three lines of approximately 8- 8-10 characters (including spaces). Please write how you would like your sign name to read, using abbreviations if need be. Group Name on Sign: _________________ ____________________ ___________________ Line 1 Line 2 Line 3 Schedule of Cleanups Please e-mail, mail, or fax or mail completed form to Gwinnett Clean & Beautiful 0000 Xxxxxxxxx Xxxxxxxxx000 X. Xxxxxx St., XxxxxxSte. 225, XXLawrenceville, 00000GA, 30046, Fax: (000) 000-0000 Please submit dates for your cleanups. These dates are used for planning purposes. By submitting these dates to us, you are not committing your group to definitely cleaning up on that date. If you’d like ; however, if you choose to change your cleanup datea date due to weather or unforeseen circumstances, simply notify our office at least 5 business days in advance by phone (000) 000-0000, fax (000) 000-0000 or email xxxxxxxxxx@xxxxxxxxxx.xxxyou must still complete a minimum of 4 cleanups per year. Group: _____________________________________________________________ Contact: _____________________________ Phone: ______________________________ First cleanup date: ___________________________________ Second cleanup date: _________________________________ Third cleanup date: :____________________________________ Fourth cleanup date: __________________________________ Optional cleanup date: _________________________________ Optional cleanup date: Post _________________________________ P ost Cleanup Form Please submit within 30 days after each cleanup to: Submit online via our website at xxx.xxxxxxxxxx.xxx/xxxxxxxxx/xxxxx-x-xxxx-xxxx-xxxxxxx/ or Fax: 770/000-0000, Email: xxxxxxxxxx@xxxxxxxxxx.xxx Mail: 0000 Xxxxxxxxx Xxxxxxxxx000 X. Xxxxxx St., XxxxxxSte. 225, XX 00000 Lawrenceville, GA, 30046 OR Submit online via our website at xxx.xxxxxxxxxx.xxx/xxxxxxxxx/xxxxx-x-xxxx-xxxx-xxxxxxx/ CONTACT INFORMATION Group Name: _________________________________________________________ Contact name: __________________________ Phone: ( ) (_____)________________ Email address: _______________________________________ Mailing address: ______________________________________________________ City Zip ______________________________ Zip_____________ CLEANUP DETAILS Date of Cleanup: _______________ Location of Cleanup: _______________________ # of bags of garbage you collected: _______ # of illegal signs you collected: ________ Approximate weight of total litter and garbage collected (20lbs/bag plus approximate weight of other large items): _______ # of volunteers: _______ # of hours worked: _______ Do you need the Department of Transportation to pick up the bags? Yes No If yes, you must also be able to answer yes to the following questions: Are the bags within the right-of-way (area between the utility pole and curb)? Is the trash located next to an intersection and clearly visible? Are there any other items other than bags that need to be removed? If yes, please describe the type and amount: ____________________________________________ Intersection where the trash is located for pick-up: _____________________________________________________________________ Comments or suggestions: Individual Registration Form Please email, fax, or mail completed form to Gwinnett Clean & Beautiful 0000 Xxxxxxxxx Xxxxxxxxx, Xxxxxx, XX, 00000, Fax: (000) 000-0000 The following persons will participate in one or more litter pick-ups. By their signatures they agree to abide by the Sponsors’ guidelines and to not hold the Sponsors responsible for any injuries they may suffer or damages that they may cause or suffer as a result of participation in the Adopt-A-Road Program. No one under the age of 12 will be allowed to participate in the Adopt-a-Road program. Note: Participants under the age of 18 will require a signature from a parent or guardian on the Youth Registration Form and do not need to sign below. Group Name: Phone: ( )_______________________________________________ _____________________________________________________________________ gwinnettcounty
Appears in 1 contract
Samples: Program Agreement
