Adopt a Road/Spot Supply Request Form
Please note: Requests to pick up supplies earlier than the earliest available pickup date cannot be accommodated. The earliest pickup date is two weeks from the date your request is submitted."
Your Full Name
*
First Name
Last Name
Email Address
*
example@example.com
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Clean-up Date
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Requested Date for Supply Pickup
*
What did you "Adopt"?
*
Spot
Road
Name of Adopted Road or Spot
*
If Road, Section of Adopted Road (If entire road is adopted please type 'All')
Number of Volunteers
*
Bags
*
Yes
No
Safety Vests for Adopt-a-Road Clean-ups
*
Yes
No
Gloves
*
Yes
No
Grabbers (Due to limited supply, grabbers may not be available for every volunteer. Grabbers MUST be returned within a week of cleanup date)
*
Yes
No
I agree to follow all AAR/AAS program rules and return any borrowed grabbers within one week of the cleanup.
*
Agreed.
Comments / Special Requests
Submit Request
Should be Empty: