Form Center

2. First Name*
   Hereafter referenced as "Entity".
3. Last Name*
5. Entity agrees to:
   Keep Winston-Salem Beautiful, Inc. (hereafter “KWSB”) and Entity (name of business, organization or individual”) recognize the need and the desirability for clean and litter-free City streets. The Adopt-A-Street program has been established for community and civic organizations as well as private businesses and industry to contribute toward the effort of maintaining cleaner and more beautiful streets in the City of Winston-Salem. The purpose of Keep Winston-Salem Beautiful, Inc.’s Adopt-A-Street program is to encourage community residents and organizations to adopt a City street or streets and keep them clean and litter-free. The adopted street(s) are to be cleaned no less than every 3 months in an effort to maintain a healthy environment and to produce feelings of pride in our beautiful City. The Entity understands that the work to be performed can result in physical injury or damage to property and agrees to assume the risk. The Entity hereby agrees to release and hold harmless the City of Winston-Salem, KWSB, and any neighborhood committee, their officers, employees and agents respectively from liability for any and all claims, damages or injuries of any kind or nature which the Entity, its employees, members or agents may cause or suffer as a result of participation in the program. All participants must sign a waiver of liability. All participants must be age 12 or older. The Entity agrees that a sign bearing the group’s name will be installed solely at the discretion of KWSB.
7. Text on Adopt-A-Street Sign*
   Name of group or individual adopting the street.
9. Street(s) to be adopted*
   Describe exactly the portion of the street you are adopting (ex: Patterson Ave. from XXXX block to XXXX block)
11. The Entity volunteers are to pick up litter and recyclables at least every 3 months (or more if desired) at their adopted street for a period beginning:
12. Start & End Dates*
    Start & End Dates Start Date

    —

    Start & End Dates End Date
    Contract must be for at least 4 years
14. Items provided for clean-up are: Clean-up reports (to be turned in after every clean-up), gloves, trash and recycling bags, and safety vests. If safety vests are misplaced, the Entity will be responsible for their replacement. NOTE: Most items collected by Adopt-A-Street participants should be litter or recyclables that can fit into bags provided. Bags should not exceed 20-25 pounds. Bags will be collected by City staff if there are more than 3 bags and they are placed in a location easily accessible by a City truck. Please place bags in convenient clusters and separate trash from recyclables. Bags should NOT be placed in the road or on sidewalks. Bulky items should be placed in a separate pile and NOT on top of under the trash bags. DO NOT collect yard waste like branches and leaves. Recycling includes CLEAN glass bottles, metal cans and plastic bottles. An Adopt-A-Street volunteer should call KWSB (336-403-7824), or email georges@cityofws.org the next working day following the cleanups to report the location of bags and bulky items. Disposal of 3 or fewer bags are the responsibility of the Entity.
16. Adopting Group Contact Information
18. First Name*
    Primary Contact Person
19. Last Name*
21. Address
23. City
24. State
25. ZIP Code
27. Phone Number*
28. Email Address
30. First Name
    Secondary Contact Person
31. Last Name
33. Address
35. City
36. State
37. ZIP Code
39. Phone Number
40. Email Address
42. By submitting this form, you are agreeing to all terms set forth in the agreement.
Leave This Blank:


44. 1. Receive an email copy of this form.
45. Email address

    This field is not part of the form submission.

46. Submit

* indicates a required field