2. Adopt-A-Block Clean-Up Form
4. Leader Name*
6. Business/Organization Name*
8. Date of Clean-Up*
10. Trash Conditions at Site*

    1. High
    2. Medium
    3. Low
12. Number of Volunteers*
14. Length of Time Worked in Minutes
16. Number of Bags of Trash*
18. Most Common Type of Trash*

    1. Cigarette Butts
    2. Cups
    3. Food Wrappers
    4. Glass Bottles
    5. Metal Cans

    1. Plastic Shopping Bags
    2. Plastic Bottles
    3. Straws
    4. Takeout Containers
20. Second Most Common Type of Trash

    1. Cigarette Butts
    2. Cups
    3. Food Wrappers
    4. Glass Bottles
    5. Metal Cans

    1. Plastic Shopping Bags
    2. Plastic Bottles
    3. Straws
    4. Takeout Containers
22. Anything else to add?
24. Please upload photos of the site before, during, and after clean-up. Photos may be used in program promotion and reports.
Leave This Blank:


26. 1. Receive an email copy of this form.
27. Email address

    This field is not part of the form submission.

28. Submit

* indicates a required field