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Adopt-A-Street Application Form

2. How are you volunteering?*

   1. As an individual/family
   2. As an organization
3. Group / Organization / Family Name
4. Number of Participants
6. I understand that the Primary Applicant/Group contact must be over 16 years of age.

   1. I understand
10. First Name*
11. Last Name*
13. Address*
15. City*
16. Postal Code*
18. Email Address
20. Phone Number 1*
21. Phone Number 2
23. Preferred Contact Method*

    1. Email
    2. Mail
    3. Phone
27. Organization Alternate Contact
29. First Name
30. Last Name
32. Email Address
34. Phone Number 1
35. Phone Number 2
39. Adopt-A-Street Information
41. Location to Adopt*
    Please be as detailed as possible.
43. I agree to commit to this program for a minimum of one year.*

    1. I agree
45. Do you wish to be publicly recognized?*

    1. Yes
    2. No
46. If yes, what would you like to see on your Adopt-a-Street signs?*
    Example: “The Smith Family”
48. Additional Notes or Comments
52. By checking this box, I acknowledge that I understand and agree to the terms outlined in Coquitlam’s Adopt-a-Street Program Agreement Form.*

    1. I understand and agree
53. View Coquitlam’s Adopt-a-Street Program Agreement Form.
    Adopt-a-Street Program Agreement Form (PDF)
55. By checking this box, I acknowledge that I understand and agree to the terms outlined in Coquitlam’s Adopt-a-Street Program Release and& Waiver Agreement.*

    1. I understand and agree
56. View Coquitlam’s Adopt-a-Street Program Release and Waiver Agreement.
    Adopt-a-Street Program Release and Waiver Agreement (PDF)
58. By checking this box, I acknowledge that I have read and agree to abide by Coquitlam’s Adopt-a-Street Program Safety Checklist.*

    1. I have read and agree
59. View Coquitlam’s Adopt-a-Street Program Safety Checklist.
    Adopt-a-Street Program Safety Checklist
61. I agree to receive periodic notifications regarding the Adopt-A-Street Program.*

    1. Yes
    2. No
63. I understand that I am responsible to ensure that Adopt-A-Street has my current and accurate contact information, and that failure to do so may result being removed from the program at the coordinator’s discretion.*

    1. Yes
    2. No
65. By checking "I consent" you are consenting to the voluntary collection and use of your personal information in accordance with Section 26(d) of the Freedom of Information and Protection of Privacy Act (the “Act”). The information provided by you will be used solely for the purposes of the Adopt-A-Street Program and will not be used for any other purpose. If you have any questions about the collection, storage, correction and/or use of your personal information please contact Tara Pastora, 500 Mariner Way at 604-927-6205.*

    1. I consent to my name being recognized in a public manner for my contribution (i.e. online or in a printed publication).
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67. 1. Receive an email copy of this form.
68. Email address

    This field is not part of the form submission.

69. Submit

* indicates a required field