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DPW Helping Hand Neighborhood Cleanup
APPLICATION FORM – APPROVAL #
Date of Event:
Event Location:
Sponsor/Coordinator Name/Contact Person:
Event Location
Street Address
City
State
Zip
Telephone #Day
Fax
Email
Alternate Contact Person:
Alternate Contact Person: Phone Number
Services/Materials Needed (Please indicate number needed)
tool kit(s)
trash bag
Location 1
Location 2
Location 3
Deliver tool kit(s) to
Full Address
Street Address
City
State
Zip
Phone Number
Phone Number
Delivery Preference: Day/Time
Morning (7am to Noon)
Afternoon (Noon to 4pm)
Evening (4pm to 7PM)
Agreement
I have read and fully understand the DPW Helping Hand Program policy. I understand that all participants in my organization are volunteers and I am responsible for each participant’s behavior. In consideration of my acceptance as a participant in the Helping Hand Program, I agree to release the Department of Public Works and all sponsors of any and all claims which may arise as a result of any expenses, personal injuries,loss or damage incurred by my organization group.I understand that an adult will accompany any volunteer under the age of 21. I further agree that any items in the tool kit(s) if lost or damaged will be paid for or replaced by articles of equal value.
Initials of Coordinator
Date:
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