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2. Name of Adoptee Organization (This name will appear on signage).*
4. First Name of Adoptee Organization Representative*
6. Last Name of Adoptee Organization Representative*
8. Mailing Address of Adoptee Organization*
10. Address Line 2
12. City
13. State
14. Zip
16. Phone Number*
17. E-mail address
19. Name of Street to Adopt*
21. Name of cross street*
22. Name of cross street*
23. Name of cross street
25. Number of blocks or miles adopting*
27. Date of Cleanup #1*
    Date of Cleanup #1
28. Date of Cleanup #2*
    Date of Cleanup #2
29. Date of Cleanup #3*
    Date of Cleanup #3
30. Date of Cleanup #4*
    Date of Cleanup #4
32. How did you hear about the Springfield Adopt-a-Street Program?*

    1. Springfieldtn.gov website
    2. Facebook
    3. Instagram
    4. Twitter
    5. City of Springfield newsletter
    6. Billboard
    7. News Source
    8. Word of Mouth
    9. Flyer
    10. Other
34. The City of Springfield will provide the following:
    1. Volunteer Group Procedures and Safety Guidelines
    2. Safety Vests
    3. Trash Bags
    4. Gloves
    5. Recognition sign in the adopted area
    7. Collection of filled trash bags
36. The Individual/Organization/Group listed above agrees to the following:
    1. The individual/organization/group coordinator will hold a safety meeting with all volunteers prior to each pick-up. All volunteers must read and understand the safety procedures and sign a waiver. The waiver must be returned to the City of Springfield’s Adopt-a-Street Program Coordinator prior to the cleanup date.
    2. Volunteers must wear safety vests provided and understands that work begins after safety signage is in its proper place.
    3. Post caution signage at the beginning and end of the adopted street facing oncoming traffic prior to removal of debris.
    4. Leave the trash bags at a designated site within the adopted area.
    5. Obtain materials and supplies at the Public Works Department located at 2809 Clinard Drive, between the hours of 8:00 a.m. and 3:00 p.m. Monday through Friday, excluding holidays, and return unused materials within three days after the date of the cleanup.
    6. The individual/organization/group hereby acknowledges that it is aware of the potential hazard implicit in the work to be performed.
    7. The individual/organization/group shall assume all responsibility for and shall indemnify, defend and hold harmless the City of Springfield, its officers, employees, heirs, agents from and against all claims, demands, actions, judgments, settlements, and damages of every nature, degree, and kind (including direct, indirect, consequential, incidental, and punitive damages), for any injury to or death to any person, for the loss of or damage to any property whatsoever (including but not limited to property owned by or in the care, custody, or control of the City of Springfield, its officers, employees, or agents) arising directly or indirectly from the performance of work pursuant to this Memorandum of Understanding. The individual/organization/group shall provide counsel to defend the City of Springfield, its officers, employees, heirs, and agents or pay the reasonable attorney’s fees and court costs of the City of Springfield, its officers, employees, and/or agents incurred in defense of any such action.
    8. All participants will be at least 12 years of age and those 17 and younger must be adequately supervised by one or more adults.
38. Acknowledgment*

    1. I agree
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40. 1. Receive an email copy of this form.
41. Email address

    This field is not part of the form submission.

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