Cleanup Coordinator Registration Form
Coordinator Name(s): ______
Hosting Business/Organization Name:______
Phone: ______Email Address:______
Date(s) of your Event: ______ Time of your Event:______
Event Name(s): ______
Event Location Name & Address (to list location on website): ______
City: ______ ZIP:______
Type of Event (litter pickup, recycling drive, beautification efforts, etc.): ______
Please briefly describe your event: ______
______
Estimated Number of Volunteers:______
Shipping Address (where UPS can deliver): ______
City: ______ ZIP: ______
Do you prefer to pick up supplies at our Little Rock warehouse or have them shipped to you? Pick Up Ship
Your supplies will be ready for pickup/delivery two weeks prior to the date of your event. Please let us know if you need them sooner.
Supplies
Thanks to support from Keep America Beautiful and other national sponsors, we are able to provide the following cleanup supplies. Please let us know which supplies you would like to request for your event.
Trash Bags VinylGloves T-Shirts Promotional Toolkit
Safety Vests Cotton Gloves Signage
In consideration for materials and support received, I agree to identify our community cleanup as a Keep Arkansas Beautiful cleanup in Arkansas event using the graphic brand as supplied. In the event that the local annual cleanup is, by custom, identified as another named event (e.g., “Annual Litter-Getter’s Pick-Up”), I agree to co-brand the event, identifying the local event as a part of the Keep Arkansas Beautiful cleanup campaign, using the graphic brand as supplied. I also agree to submit our final wrap-up report to the Keep Arkansas Beautiful office within 10 days following our last scheduled event, so that our event totals can be included among Arkansas’s statewide cleanup accomplishments.
Signature: Date:
Please return this form to: Keep Arkansas Beautiful, ATTN: Liz Philpott, One Capitol Mall, Suite 4A-007,Little Rock, AR 72201; fax to 501-682-2383; or email to . Liz can be reached toll-free at 888-742-8701.