Adopt a Road/Spot Supply Request Form
Request supplies with available dates starting in two weeks
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
Date
Requested Date for Supply Pickup
*
What did you "Adopt"?
*
A Road
A Spot
Name of Adopted Road or Spot
*
If Road, Section of Adopted Road (If entire road is adopted please type 'All')
Number of Volunteers
*
Bags
*
No
Yes
Safety Vests for Adopt-a-Road Clean-ups
*
No
Yes
Gloves
*
No
Yes
Grabbers (Due to limited supply, grabbers may not be available for every volunteer. Grabbers MUST be returned within a week of cleanup date)
*
No
Yes
Comments / Special Requests
By checking yes to this box I agree the grabbers (if requested) will be returned within one week of the clean up, and my group will follow all rules of the AAR/AAS program.
*
No
Yes
Submit Request
Should be Empty: