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2. GROUP INFORMATION
4. Type of Group*

   1. Civic Group
   2. Not for Profit Group
   3. Private Enterprise/Commercial
   4. Family/Friends
5. Type of Application*

   1. New
   2. Renewal
7. Group Name
8. Group Coordinator*
10. Telephone number*
11. Email Address*
13. Street Address*
14. City State Zip*
16. Approximate Number of Participants per Cleanup*
18. Adult Supervision

    If participants are under 18 years old, adult supervision is required, with an average of one adult per seven individuals under 18 years old.   Will your group be able to supply an adequate number of adults per cleanup?

20. We will have adequate adults for supervise cleanup.*

    1. Yes

    1. No
24. WHAT WILL APPEAR ON SIGNAGE
26. Name/Acronym*

    Name/Acronym will appear on the sign.  No logos or slogans will be allowed. Program Director may request modification to the name that will be printed on the signs.  Limit will be 17 characters per line, two lines.  Leave spaces between words.

30. ROAD SELECTIONS
32. First Choice - Section of Roadway to be adopted
34. Name of Road*
35. From/To:*

    Include the cross streets at both ends of the road your group is adopting.  For example, "Washington Street to Grand Avenue."

37. Second Choice - Section of Roadway to be adopted
39. Name of Road*
40. From/To:*

    Include the cross streets at both ends of the road your group is adopting.  For example, "Washington to Grand Avenue."

44. SIGNATURE

    I hereby certify that the above information is correct and my Group/Organization agrees to conform to the requirements of the City of Waukegan Adopt-a-Road program as outlined below in Ordinance 22-O-26.

46. Ordinance 22-O-26
48. I read and agree to conform to the Ordinance.*

    1. Yes

    1. No
50. Electronic Signature of Group Coordinator*
51. Signature date*
    Signature date
Leave This Blank:


53. 1. Receive an email copy of this form.
54. Email address

    This field is not part of the form submission.

55. Submit

* indicates a required field