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2. 

5. Please complete this form after finishing each cleanup event.
   

7. Event Date:*
   Event Date:

9. To: City of Hollywood 

   Public Works Dept. 

   Attn: Megan Wyatt

   1600 S. Park Road

   Hollywood, FL 33021 

10. Phone: 954-967-4526

    Fax: 954-967-4510

    E-mail: mwyatt@hollywoodfl.org

12. From:*

    Group Leader

13. Phone No.*
15. Name of Organization/Group:*
17. Email address:*
19. Adopt-A-Street Location:*
    -- Select One --Arthur StreetGlenn ParkwayHarding StreetJa Ely Boulevard/ 22ndAveJoe DiMaggio DriveJohnson StreetMoffett StreetN. 12 AvenueN. 14 AvenueN. 23 AvenueN. 24 AvenueN. 56 AvenueN. 64 AvenueN. 68 AvenueN. 72 AvenueNorth Park RoadS Park RoadS. 12 AvenueS. 24 AvenueS. 46 AvenueScott StreetShannandoah StreetSurf RoadTaft StreetThomas StreetVan Buren StreetWashington Street
21. From:*
    -- Select One --441Forrest StreetHarding StreetHollywood BoulevardJohnson StreetN. 16 AvenueN. 35 AvenueN. 46 Avenue N. 56 AvenueN. 72 AvenueN. North Lake DriveN. Park RoadN. South Lake DrivePolk StreetS. 20 AvenueSheridan StreetSW 3 PlaceTaft StreetU.S. 1Washington Street
22. To:*
    -- Select One --Arthur StreetFranklin StreetFreedom StreetGreene StreetJohnson StreetKnights RoadN. 11 CourtN. 14th AvenueN. 15th AvenueN. 26 AvenueN. 30 RoadN. 56 AvenueN. 66 AvenuePembroke RoadPierce StreetS. 14 AvenueS. 37 AvenueS. 56 AvenueS. North Lake DriveS. South Lake DriveSheridan StreetState Road 7Stirling RoadTaft StreetTurnpike (Dead End)Washington Street
24. Number of hours involved:*
26. Number of volunteers:*
28. Number of trash bags:*
30. Location of trash bags to be picked up:
32. Date of anticipated next event:*
    Date of anticipated next event:
34. List any unusual or large items encountered:
36. Are signs OK?*

    1. Yes

    1. No

38. We encourage recycling; however, the nature of roadside litter may not be conducive to recycling. Any materials collected for recycling, as well as any income derived from them, shall be the property of the volunteers.

Leave This Blank:


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

    This field is not part of the form submission.

42. Submit Submit and Print

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