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Event Completion Form

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City of Fort Lauderdale
Adopt-A-Street
Event Completion Form

Please correct the field(s) marked in red below:

Please complete the form below after each cleanup event. If you have any questions, please email adoptastreet@fortlauderdale.gov.
1
Date of Cleanup event:
 *
2
Contact Information. 
 *
Contact Information.
3
Cleanup Metrics
 *
Cleanup Metrics
4
Trash Location: 
5
Green Your Routine:
6
Photo Upload:
7
Miscellaneous Information:
Miscellaneous Information:
8
Condition of Adopt-A-Street Sign:
 *
Condition of Adopt-A-Street Sign:
9
Approximate Date of Next Event:
 *

10

Participation Waiver

In consideration of the privilege of being allowed to take part in the City of Fort Lauderdale's Adopt-A-Street Program, use of equipment and the facilities of the City, and for other good and valuable consideration, the receipt and sufficiency of which is hereby acknowledged and undersigned, individually and on behalf of my minor child names below do hereby agree to indemnify and hold harmless the City of Fort Lauderdale, its trustees, elected and appointed officials, agents, servants, volunteers, and employees from and against all claims, demands, causes of action of whatsoever kind, and for any resulting judgments, losses, costs, damages, liability, expenses, including, but not limited to attorneys' fees arising out of, occurring during or relating to the use of equipment, facilities, or participation in the City's program. 

I further acknowledge and authorize the photograph and videotape and publication of such photographs and videotapes of my minor to promote or publicize the City's programs. I understand the physical requirements of participation in these activities and affirm that my child meets these requirements. I give permission for instructor, staff, and emergency personnel to make necessary first aid decisions in the event of accident, injury, or illness. In the case of injury, accident, illness, or inability to complete these activities, I will bear the full cost of any expense incurred due to any injury to my child or damage to my property. 

Participation Waiver In consideration of the privilege of being allowed to take part in the City of Fort Lauderdale's Adopt-A-Street Program, use of equipment and the facilities of the City, and for other good and valuable consideration, the receipt and sufficiency of which is hereby acknowledged and undersigned, individually and on behalf of my minor child names below do hereby agree to indemnify and hold harmless the City of Fort Lauderdale, its trustees, elected and appointed officials, agents, servants, volunteers, and employees from and against all claims, demands, causes of action of whatsoever kind, and for any resulting judgments, losses, costs, damages, liability, expenses, including, but not limited to attorneys' fees arising out of, occurring during or relating to the use of equipment, facilities, or participation in the City's program. I further acknowledge and authorize the photograph and videotape and publication of such photographs and videotapes of my minor to promote or publicize the City's programs. I understand the physical requirements of participation in these activities and affirm that my child meets these requirements. I give permission for instructor, staff, and emergency personnel to make necessary first aid decisions in the event of accident, injury, or illness. In the case of injury, accident, illness, or inability to complete these activities, I will bear the full cost of any expense incurred due to any injury to my child or damage to my property.
Participant's Name Check to Acknowledge the Above Waiver
Participant #1
Participant #2
Participant #3
Participant #4
Participant #5
Participant #6
Participant #7
Participant #8

PLEASE FOLLOW THE BASIC SAFETY RULES:

  • Always wear the orange/green safety vest and gloves.
  • All volunteers should walk on the same side of the street. 
  • Program is for children 12 years of age or older; provide adult supervision for minors. 
  • Please examine all litter for sharp edges before picking up. 
  1. To receive a copy of your submission, please fill out your email address below and submit.