Adopt-A-Street or Park Application

Adopt-A-Street Volunteer Program Application
Please fill out the following application as the group representative to participate in the Adopt-A-Street or Adopt-A-Park programs. Thank you.
Primary contact

First NameLast Name
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip code
Phone number
Please enter a valid phone number.Format: (000) 000-0000.
Email
example@example.com
Emergency contact

First NameLast Name
Emergency contact's phone number
Please enter a valid phone number.Format: (000) 000-0000.
Emergency contact's email address
example@example.com
Secondary group contact (if applicable)

First NameLast Name
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip code
Phone number
Please enter a valid phone number.Format: (000) 000-0000.
Email
example@example.com
Official name of group
This will appear on the group street sign.
Adoption information: route or park
Length of route

GROUP SIGNS

Required cleanups

12 per year = One cleanup per month and submit litter removal form
Number of volunteers
Number of adults
Number of minors
A waiver must be signed for minors.

Please provide number of each size T-shirt
Small
Medium
Large
XL
2XL

Adopt-A-Street or Park Application
THIS AGREEMENT, made and entered into this

MonthDayYear
Date
by and between the CITY OF PORT ST. LUCIE herein-after called the "CITY" and
Group Name (herein-after called the "GROUP".)
WHEREAS
Name of streets or park
is part of the street system in Port St. Lucie, Florida.

WHEREAS the CITY is authorized to contract with the private sector for the performance of its duties.

WHEREAS the CITY has encouraged the implementation of an Adopt-A-Street program for the participation of local individuals or organizations in specific litter removal projects.

WHEREAS the GROUP is agreeable to adopting "removing litter" the section of road right-of-way identified on the application and summarized above on this agreement.

NOW THEREFORE, the parties agree as follows:

THE GROUP SHALL:
A.    Shall receive a safety video and conduct a safety meeting prior to the group's first cleanup. It is the responsibility of the group leader/representatives identified on the application to ensure that each new participant views and fully understands the safety video, program guidelines and obtains signed forms by each participant.

B.    Prior to any litter removal activities, contact Keep Port St. Lucie Beautiful 772-871-5103 to arrange an appropriate litter removal schedule.

C.     Perform litter removal activities in the agreed to section(s) of road right-of-way adjacent to the street identified in this agreement/application a minimum of twelve times a year or more as necessary.

D.    Contact Keep Port St. Lucie Beautiful if any special accommodations are required by any GROUP member to safely perform the volunteer activities. The CITY will make reasonable accommodations as requested by the applicant.

E.     Remove litter during daylight hours and during non-inclement weather conditions only.

F.     Ensure all participants wear gloves or use proper litter removal tools and trash bags.

G.    Ensure all participants wear proper clothing and bright-colored shirts or safety vests. Proper shirts are provided to all participants and safety vests can be provided upon request.

H.       Have a working cell phone and a first-aid kit on hand.

I.       Only allow such persons to participate as are determined by the GROUP to be responsible enough to safely participate in the litter removal activities. The minimum age of participants is ten (10) years old.

J.    Provide one adult supervisor for every five (5) youths ages ten (10) to seventeen (17).

K.     Avoid picking up litter in construction areas, road medians or in a street with high- traffic volumes.

L. Avoid lifting heavy or dangerous objects. Report any dangerous or suspicious items to the program coordinator or call 911.

M.    Submit a minimum of one (1) litter removal form every month after each cleanup = twelve (12) annually

N. Report any injury accidents to the program supervisor at 772-871-5103 or call 911.
THE CITY (OFFICE OF SOLID WASTE) SHALL:

A.     Issue the safety video, safety checklist and other program materials that are provided as part of this program.

B.     Provide permanent Adopt-A-Street signs as applicable and identified on page one of the application.

C.     Provide T-shirts (or safety vests) for all active participants in the program.

D.     Remove trash bags from the roadway section when requested by the group.

E.     Monitor compliance with program terms.
II.
First NameLast Name
I, on behalf of the GROUP covenants and agrees that we will indemnify and hold harmless the CITY, any maintaining agencies and all of their officers, agents and employees from any claim, loss, damage, cost charges or expense arising out of any act, action, neglect or omission by the GROUP during the performance of this agreement, whether direct or indirect, and whether to any person or property to which the CITY or said parties may be subject, except that neither GROUP nor any of its members shall be liable under provision for damages arising out of injury or damage to persons or property directly caused or resulting from the sole negligence of the CITY, any maintaining agencies, and all their officers, employees or agents.
III.
This agreement shall be non-lapsing; However, the CITY or GROUP may terminate this agreement for any reason upon thirty (30) days’ notice if deemed necessary to either party.
IV.
This agreement is for litter removal activities only. Any beautification activities must be pursued by another method.

IN WITNESS WHEREOF, the parties hereto caused these present to be executed, the day and year first written above.

APPLICANT STATEMENT
On behalf of this group, I have read and agree to the Procedures for the City of Port St. Lucie's Adopt-A-Street Litter Removal Program. I understand the hazardous nature of the work that is to be performed and take responsibility for the group's participation in the program. I also agree to notify the City of any changes in contact information or if a new contact person assumes responsibility for the group. I also understand members of my group are required to watch the Safety Video and submit confirmation report and may be subject to a criminal history background check.
Name

First NameLast Name
Name of group:
Today's date

MonthDayYear
Date
Should be Empty:

Adopt-A-Street Volunteer Program Application

GROUP SIGNS

Required cleanups

Please provide number of each size T-shirt

Adopt-A-Street or Park Application

II.

III.

IV.

APPLICANT STATEMENT