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
Adopt-A-Street groups are eligible for a sign in their designated areas that they keep clean. If you do want a sign for your designated area, it will be posted by our Traffic Operations division in a location appropriate for the existing conditions.
Do you want a sign?
Do you want a sign?

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.

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
2 digit month, 2 digit day, 4 digit yearDate
Please sign
Should be Empty:

Adopt-A-Street Volunteer Program Application