Adopt A Road Litter Control Program Application Date of Application: Name of Organization or Group: Contact Person: Home Phone: Cell Phone: Mailing Address: E-mail Address: Are any volunteers younger than 18 years of age? Yes No (If yes, for every volunteer under 18 years old, fill out the Minor Participation Permission form. There must be 1 adult supervisor for every 6 minors on the day of the cleanup.) Approximate number of people participating in litter cleanup effort: Road segment organization or individual interested in adopting: Please email application to: mgg@cityofmiltonga.us or fax: 678-242-2499 For information contact: Barbara Peck, Volunteer, Adopt-A-Road Coordinator 404-368-8280, barbaraapeck27@gmail.com Teresa Stickels, Sustainability Coordinator, City of Milton 678-242-2509, teresa.stickels@cityofmiltonga.us Adopt-A-Road Program Milton Grows Green City of Milton 13000 Deerfield Parkway, Suite 107 G Milton, GA 30004 Department Review Date: Approval #
Adopt A Road Litter Control Program Description The Adopt-A-Road program is administered by the Milton Grows Green Committee of the City of Milton. The program aims to help maintain the appearance of our city by holding routine clean ups (sweeps) of local streets. Any subdivision, club, organization, business, school, church, family or individual interested in performing community service and in helping to improve the appearance and quality of life in the City of Milton is encouraged to participate. The Adopt-A-Road program allows groups to adopt a minimum of one mile of roadway that has been designated for adoption by the city. The Adopt a Road set up process is as follows: Once the roadway has been identified and all forms filled out and emailed or faxed to the Milton Grows Green Adopt-A-Road Coordinator, the group leader will set their first scheduled clean up date. Once the cleanup is scheduled and all safety rules have been reviewed, the group leader can pick up their Adopt-A-Road Safety Kit (safety vests, trash bags, etc), located at Milton City Hall Public Works Department. 13000 Deerfield Parkway Suite 107G Milton GA 30004. After the first cleanup, the group leader will return the safety kit to the City of Milton Public Works Department. The Waiver/Completion form and the Recognition/Sign Request form should be emailed to the Milton Grows Green Coordinator for processing at mgg@cityofmiltonga.us or faxed to 678.242.2499. Within approximately one month after submission of a sign request form, the City of Milton Public Works Department will install 2 Adopt-A-Road signs with the individual s or group s name at each end of the adopted roadway. This area must be adopted for a minimum of one year and a minimum of four cleanups should be performed each year. After twelve months, the group will have the opportunity to continue the adoption of the road if they have completed the required four sweeps. When the group decides it no longer wants to participate in the program, Milton Grows Green should be contacted so that the group or individual placard can be removed, and the road made available to other applicants. One of the goals of Milton Grows Green is to get the community involved in keeping our city a clean and safe place for citizens, visitors and businesses. With your help, we can make the City of Milton a better place to live, visit and work. For questions or if you would like to Adopt-A-Road, contact: Barbara Peck, Volunteer, Adopt-A-Road Coordinator, 404-368-8280, barbaraapeck27@gmail.com
Adopt-A-Road Recognition/Sign Request Form The Milton Grows Green committee and the City of Milton Public Works Department will install Adopt-A-Road signs acknowledging your contribution to roadside litter reduction. (Please see the example to the right.) It will take approximately one month for the signs to be installed. There will be a maximum of 2 lines with 15 characters per line (includes spaces) for the name of the individual or organization adopting the road. Please complete the following: (Please print individual s or organization s name as you would like it to appear on the sign; using one or two lines, spaces do count as a character). Group Leader Telephone Number Email Address Adopted Road Segment Location A sign will be placed near each end of the adopted section. THANK YOU for your participation. *Please note that the signs are standard in size and color. Adjustments or additions to the design, including group or company logos, cannot be made. If you have questions please email: Barbara Peck, Volunteer, Adopt-A-Road Coordinator 404-368-8280, barbaraapeck27@gmail.com
Adopt-A-Road Waiver/Completion Form Adopted Road Name Date of Clean up Group Leader Contact Phone Group Name Contact Email By signing below I certify that: I am participating and am under the control of our volunteer group and not the City of Milton. I understand and agree to abide by the Adopt-A-Road Safety Rules. I agree to release and forever discharge the City of Milton, its agents, employees and officials from any and all liability whatsoever for damages or injury resulting from my participation in this program. Volunteers are informed and acknowledge being advised that working adjacent to a roadway can be a hazardous activity which can cause bodily injury. Volunteers agree they will exercise due care and caution in performing litter pick up activities. Volunteers further acknowledge they have received safety instructions that include review of the Adopt-A-Road Rules prior to participating in any cleanup activities. Volunteers are to wear the safety vests furnished by the Public Works Department, and appropriate protective clothing during cleanup activities. Name (print) Signature Note: This form is required to be completed and returned after each cleanup. *Number of bags picked up Scan and email your form to mgg@cityofmiltonga.us or fax to 678.242.2499 Were there any unusual incidents or injuries during the cleanup? If so, please describe.
(This form must be completed for each volunteer under 18 years of age prior to participation in the program and kept on file by the Volunteer Group Leader) Name of Participant: Volunteer Group: Address: Adopt-A-Road Minor Participation Permission Form City and State: Zip: Adopt-A-Road program allows volunteers young and old to contribute towards the effort to control litter and enhance roadside and neighborhood appearance. Volunteers are informed and acknowledge being advised that working adjacent to a roadway can be a hazardous activity that can cause bodily injury. Volunteers agree to exercise due care and caution in performing litter pick up activities. Volunteers further acknowledge they have received safety instructions that include review of the Adopt- A-Road Rules prior to participating in any cleanup activities. Volunteers are to wear the safety vest furnished by the Public Works Department, and appropriate protective clothing during cleanup activities. By signing below I certify that: I am participating and am under control of our volunteer group and not the city of Milton. I understand and agree to abide by the Adopt-A-Road Safety Rules. I agree to release and forever discharge the city of Milton, its agents, employees and officials from any and all liability whatsoever for damages or injury resulting from my participation in this program. Signed Print Child s Name Date Parent/Legal Guardian Permission and Assumption of Liability As parent/legal Guardian I, (print name) hereby grant my permission for the minor child named above to participate in the Adopt-A-Road program. I acknowledge, agree and understand that participation involves risks and inherent dangers that could cause injury and/or death. On behalf of myself and the minor child above I agree and release and forever discharge the city of Milton. Signed Date Emergency Medical Treatment Authorization As Parent/Legal Guardian of the above minor child volunteer I, authorize qualified emergency medical personnel, including a physician and staff, to examine the above named minor child, in the event of injury, and to administer emergency care and to arrange for any consultation by specialists, including a surgeon, as deemed prudent for proper care of any injury. Every effort will be made to contact the Parent/Legal Guardian prior to any treatment. Signed Date
Adopt-a-Road Safety Rules Volunteers in the Milton Grows Green ADOPT-A-ROAD program must comply with the following ADOPT-A-ROAD safety rules. The following list is not all inclusive and is not a substitute for common sense: volunteer group leaders and volunteers agree to make safety the first priority during ADOPT-A-ROAD cleanups. Wear the safety vest provided at all times. Be prepared for any unexpected behavior of motorists. Never assume a driver sees you. Clean only one side of the road at a time and walk facing oncoming traffic. Place the Volunteer Litter Crew Ahead warning sign facing traffic at the start of the section of roadway being cleaned. Do not stand or jump on guardrails, drainage pipes, or concrete walls. Never enter the roadway to pick up trash. Do not wear headphones or use a cell phone to text or call during a clean-up except for an emergency. Do not drink alcohol prior to or while participating in clean-up events. Do not handle hazardous materials such as car batteries, petroleum products and chemical spills, heavy or unwieldy objects, dead animals, broken glass, needles and drug paraphernalia, or any unidentified questionable items. Such items should be reported to the ADOPT-A-ROAD coordinator as soon as possible for proper disposal. Know emergency procedures and make sure someone has a cell phone in your group to dial 9-1-1 in an emergency. Notify the volunteer group leader of all known allergies and any physical limitations prior to your participation. Avoid overexertion and heat-related problems by drinking water and taking breaks. Carpool to the litter pickup site and pull vehicles as far off the side of the road as possible. Vehicles should never be parked on the traveled portion of the roadway. Wear long sleeves, long pants, think-soled shoes or boots, and gloves. Perform cleanup activities only during daylight hours and when weather is conducive to good visibility. Avoid peak traffic hours and extreme inclement weather conditions. Stay clear of all construction areas. Avoid all horseplay of any nature. Do not distract drivers. Be careful of contact with poisonous plants, stinging insects, or stray/wild animals. Report all accidents or injuries to the volunteer group leader immediately. Tie orange trash bags securely and leave about 10ft. off the roadway for pick up by the City of Milton Public Works Department. Return your clean up kit and waiver/completion form to the City of Milton Public Works Department as soon as possible after each the clean up event. Should you experience an emergency, please dial 911 immediately. For non emergency questions, please call Barbara Peck, Volunteer Coordinator at 404-368-8280, or email barbaraapeck27@gmail.com Thank you for your help!