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2. First Name*
   Hereafter referenced as "Entity".
3. Last Name*
5. Purpose and Mission Statement
   Keep Winston-Salem Beautiful, Inc. (hereafter “KWSB”) and "Entity" (name of business, organization or individual, hereafter the “Entity”) recognize the need and the desirability for clean and litter-free City parks. The Adopt-A-Park 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 parks in the City of Winston-Salem. The purpose of Keep Winston-Salem Beautiful, Inc.’s Adopt-A-Park program is to encourage community residents and organizations to adopt a city park and keep it clean and litter-free. The adopted park is 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. The Entity agrees that a sign bearing the group’s name will be installed solely at the discretion of KWSB.
7. Text for Adopt-A-Park Sign*
   Name of the individual or group adopting the park
9. KWSB recognizes the Entity of the adopting organization for:*
   Name and location of park
11. The Entity volunteers are to pick up litter and recyclables at least every 3 months (or more if desired) at their adopted park.
13. Start and End Dates*
    Start and End Dates Start Date

    —

    Start and End Dates End Date
    Commitment is 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 needed). If safety vests are misplaced, the Entity will be responsible for their replacement.
16. Note:
    Most items collected by Adopt-A-Park 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-Park volunteer should call KWSB (336-403-7824) the 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.
18. Adopting Group Contact Information
    List primary and secondary contact information.
20. First Name*
    Primary contact person
21. Last Name*
23. Address
24. City
26. State
27. ZIP Code
29. Phone Number*
30. Email Address
32. First Name
    Secondary contact person
33. Last Name
35. Address
36. City
38. State
39. ZIP Code
41. Phone Number
42. Email Address
44. By submitting this form, you are agreeing to all terms set forth in the agreement.
Leave This Blank:


46. 1. Receive an email copy of this form.
47. Email address

    This field is not part of the form submission.

48. Submit

* indicates a required field