PA CleanWays > Adoptions > Adoption Cleanup Reporting Form

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Thank you for participating in the PA CleanWays Adoption Program!

This form is for reporting information about registered PA CleanWays Adoption-related events. (PennDOT Adopt-A-Highway events and Great American Cleanup of PA events, unless also registered as a PA CleanWays Adoption, should be reported directly to those organizations.)

To report information about a completed PA CleanWays Adoption Cleanup event, please fill out the following form within two weeks of your cleanup and click submit. (You may report on ONLY ONE EVENT AT A TIME using this form.)

PA CleanWays Adoption Cleanup Reporting Form

lName of Person Submitting This Form: (required)
E-mail of Person Submitting This Form: (required)

Check here if you are a Litter Free School Zone participant

Primary Contact First Name: Last Name:
-----Address:
.................Daytime Phone:
-............--.....-----E-mail:

---------- Check here if your contact information has changed

----.Name of Adopted Area:
.....................Municipality:
...........................County:
...............Date of Cleanup:

Names of Groups Participating (Please put a semi-colon between group names):
---.-.

Did all volunteers sign the Volunteer Waiver Form? Yes No
(Required - please send completed forms to our office.)

Were Parental Consent Forms signed by parents of all participants under
the age of 18? Yes No
(Required - please send completed forms to our office.)

Cleanup Statistics
Total Number of Volunteers Participating in Cleanup:
Total Number of Hours Volunteers Worked: (Number of volunteers multiplied by the number of hours worked)
Total Number of Trash Bags Collected:
Total Number of Tires Collected:
Total Number of Appliances & Other Large Bulky Items Collected:

Please let us know of any problems or concerns relating to your adoption:
---.-.

Please feel free to share interesting stories, unusual items found, quotes, or other feedback about your adoption:
--.--.

When you are finished reporting Adoption Cleanup Event information,
press the "Submit Form" button below to send: