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2. 
6. Date of Application
   Date of Application
8. Name of 1st Group Leader:
10. First Name*
11. Last Name*
12. Date of Birth:*
14. Name of 2nd Group Leader:
16. First Name
17. Last Name
18. Date of Birth:
20. Number of Volunteers:
23. Length of Request:*
    -- Select One --Two yearsOne Time
24. One Time Event:
    One Time Event:
28. ORGANIZATION INFORMATION (PLEASE PRINT OR TYPE)
30. Name of Organization:
32. Mailing Address:*
34. City*
35. State*
36. Zip*
38. Email Address:*
39. Telephone:*
41. Type of Volunteers:*

    1. Business
    2. Individual

    1. Faith-Based
    2. Family

    1. Community Group
    2. School Group

    1. Corporate
    2. Other*
43. *Other: Volunteer not listed above
45. Adopt-A-Street Location:*
    -- Select One --N 72 AvenueGlenn ParkwayNorth Park RoadJohnson StreetWashington StreetS. 12 AvenueN. 64 AvenueS Park RoadTaft StreetHillcrest DriveN. 68 AvenueVan Buren StreetN. 14 AvenueN. 24 AvenueJoe DiMaggio DriveArthur StreetN. 56 AvenueN. 12 AvenueN. 14 AvenueSurf RoadS. 24 AvenueScott StreetThomas StreetShannandoah StreetHarding StreetS. 46 AvenueMoffett StreetN 23 Avenue
47. From:*
48. To:*
50. *Proposed Name of Adoption Sign

    Subject to approval by the City of Hollywood

52. ACKNOWLEDGMENT
54. Submitter of Application:*
55. Title:*
57. Signature:*
58. Date:*
    Date:
60. If you are under 18 you must provide a signature of a parent or guardian.
62. Parent/Guardian's Full Name:
63. Parent/Guardian's signature:

65. QUESTIONS/Telephone: 954.967.4526 Fax: 954.967.4510 Mailing Address: City of Hollywood, ATTN: Public Works Department, 1600 S. Park Rd., Hollywood, FL 33021 Email address: mwyatt@hollywoodfl.org

67. KEEP HOLLYWOOD BEAUTIFUL ADOPT-A-STREET STATEMENT OF COMMITMENT
    The Adopt-A-Street is a cooperative effort between the City of Hollywood and residents, businesses, or groups wishing to contribute to the appearance of their community. Both parties, therefore, commit to perform certain activities for cleaner and safer streets. It is understood that at no time is the safety of any volunteer to be compromised in the performance of any activity associated with this program
69. THE ADOPTER AGREES TO:
71. 1. By signature on the next page, the group, both jointly and severally, acknowledges the hazardous nature of the work and agree, both jointly and severally, to the following terms and conditions:
73. 2. Participants in the group agree to obey and abide by all laws and regulations relating to safety and such terms and conditions as may be required by the City of Hollywood.
75. 3. The group shall appoint or select a group leader. The group leader may obtain supplies and materials from the Public Works Department during regular business hours.
77. 4. When participants are under 18 years of age, the group leader shall furnish appropriate supervision. The group leader will ensure that all participants are responsible people.
79. 5. The group leader shall notify the City within five (5) business days in advance of a planned Adopt-A-Street project.
81. 6. The group leader shall require each and every participant or a parent/guardian if the participant is a minor, to read and sign the assumption of risks and release of liability part of the Volunteer Report.
83. 7. Groups shall be required to adopt the street for a minimum period of two years or as a one-time event. The City will review each request.
85. 8. Groups shall perform clean-up projects a minimum of four times per year.
87. 9. The group will abide by all guidelines set forth in the Adopt-A-Street program.
89. 10. The group shall be responsible for placing litter in trash bags furnished by the Public Works Department. Unused materials and supplies may be stored by the group leader.
91. 11. The group leader shall be responsible for prohibiting participants from either possessing or consuming alcoholic beverages while on City property. The group leader will discuss safety precautions with participants and ensure that the appropriate tools and equipment are used during cleanup.
93. 12. The group leader shall be responsible for maintaining a first aid kit and ensuring that all participants follow all safety standards. It is also recommended that the group coordinator be present during cleanup activities.
95. 13. The group agrees to relieve, hold harmless and indemnify the City of Hollywood, its agents, servants and employees from any and all actions, claims, injuries, damage, cost, charges or expense and lawsuits arising out of any act, action, neglect or omission by the group in furtherance of the activities connected with Adopt-A-Street.
97. 14. The group shall immediately report to the City of Hollywood any injury incurred by any participant during cleanup activities and any hazard encountered at the adopted site.
99. THE CITY OF HOLLYWOOD AGREES TO:
101. 1. Supply trash bags, gloves, can catchers, and safety vests.
103. 2. Arrange for the removal and disposal of any litter, trash, leaves and material collected from the adopted site.
105. 3. Remove large, sharp or hazardous objects reported by the group.
107. 4. Supply and install two Adopt-A-Street signs with the Adopter’s name.
109. The City or group may terminate this agreement for any reason upon 20 days written notice.
111. ACKNOWLEDGMENT
     I have read and understand this statement of commitment for the Adopt-A-Street program, and I agree to the terms of participation.
113. Organization:*
115. Name of 1st Group Leader:
117. First Name*
118. Last Name*
120. Name of 2nd Group Leader:
122. First Name
123. Last Name
125. Address:*
127. City*
128. State*
129. Zip*
131. Phone Number:*
132. Email Address:*
134. I Accept*

     1. By selecting the "I Accept" button, you are signing this Agreement electronically. You agree your electronic signature is the legal equivalent of your manual signature on this Agreement.
136. Name of 1st Group Leader Signature:*
137. Date:*
     Date:
139. Name of 2nd Group Leader Signature:
140. Date:
     Date:
142. City Representative Signature:
143. Date:
     Date:
Leave This Blank:


145. 1. Receive an email copy of this form.
146. Email address

     This field is not part of the form submission.

147. Submit Submit and Print

* indicates a required field