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2. First Name*
   Hereafter referenced as "Entity".
3. Last Name*
5. Keep Winston-Salem Beautiful, Inc. (hereafter “KWSB”), the City of Winston-Salem Stormwater Division (hereafter “Stormwater”) and Entity (name of business, organization or individual, hereafter the “Entity”) recognize the need and the desirability for clean and litter-free City waterways.
7. The Adopt-A-Stream 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 waterways in the City of Winston-Salem. The purpose of the Adopt-A-Stream program is to encourage community residents and organizations to adopt a City waterway and keep it clean and litter-free. The adopted waterway is to be cleaned no less than 3 times per year. 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, Stormwater, 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 and Stormwater.
9. Text on Adopt-A-Stream Sign*
   Name of group adopting the stream
11. KWSB and Stormwater recognize the Entity of the adopting organization for:*
    Name and location of waterway
13. Start and End Date*
    Start and End Date Start Date

    —

    Start and End Date End Date
    Contract commitment is 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 bags, and safety vests. If safety vests are misplaced, the Entity will be responsible for their replacement.
16. Note:
    Most items collected by Adopt-A-Stream 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. 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. An Adopt-A-Stream contact person 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
20. First Name*
    Primary Contract
21. Last Name*
23. Address
24. City
26. State
27. ZIP Code
29. Phone Number*
30. Email Address
32. First Name
    Secondary Contact
33. Last Name
35. Address
36. City
38. State
39. ZIP Code
41. Phone Number
42. Email Address
44. By submitting this form you agree 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