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2. Name*
4. Name of Organization*
6. Name Street or Spot*
8. Contact Phone Number*
9. Email *
11. When would you like to pick up your supplies from the Development Office (300 N Main St)? ? (Please allow 24 hours from today’s date)*
    When would you like to pick up your supplies from the Development Office (300 N Main St)? ? (Please allow 24 hours from today’s date)
13. Event Date*
    Event Date
15. Event Start Time*
    Event Start Time
16. Event End Time*
    Event End Time
18. Would you like Keep Hopewell Beautiful to promote this event? (Select Yes or No)*

    1. Yes
    2. No
20. Equipment (select amount of each that apply)
22. Vests
24. Grabbers
26. Trash Bags
28. Gloves
30. Any Additional Comments
34. CITY OF HOPEWELL ADOPT-A-STREET/ADOPT-A-SPOT DISCLAIMER

36. By signing this disclaimer, you agree with and will adhere to the following:

    "I have signed out the items checked below from the Hopewell Department of Development (Clean City Commission) located at 300 North Main Street, Room 321, Hopewell, Virginia 23860 to clean/beautify the assigned area on the assigned date.

    I understand that I am responsible for returning the items checked below to the Department of Development within four days of the date they were checked out. Should I be unable to return the items within 4 days or if the items will be returned by someone other than myself I will contact the Department of Development at (804) 541-2220 and notify them when the items will be returned and who will return them. Failure to return the items after seven (7) days of checkout will result in the suspension of the organization from the Adopt a Street/Spot Program and will require the organization to pay replacement cost of the unreturned items."

38. Electronic Signature*
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40. 1. Receive an email copy of this form.
41. Email address

    This field is not part of the form submission.

42. Submit

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