2. 
3. Adopt-a-Street

   Application for Program Designation and Agreement

5. Adopting Organization

   As stewards of the City of Spring Hill water resources, we the above-listed organization, request permission to adopt a segment of the following street:

7. Number of street clean-ups per year (4 required)
8. Street/Segment of Street*
10. Length of segment (miles)
12. First Name*

    Designated Representative (Primary)

13. Last Name*
15. Address1*
17. Address2
19. City
20. State
21. Zip
23. Phone (day time)*
24. Email

26. The work will be performed under and in accordance with the General Program Guidelines and Safety Guidelines and incorporated herein by reference. 

    Applications to whom an Adopt-A-Street Program Designation and Agreement are issued shall at all times indemnify and save harmless the City of Spring Hill, and all employees, agents, and officers from responsibility, damage, or liability arising from the exercise of the privileges granted under designated programs. The Program Designation and Agreement may be terminated by the City of Spring Hill at any time. The City of Spring Hill reserves the right to revise or discontinue the Adopt-A-Street program at any time.

    As a designated representative of the above-named organization/company, I have read, understand, and shall comply with the Adopt-A-Street general program conditions and safety guidelines regarding participation in the program.

28. Signature*
29. Date*
Leave This Blank:


30. 1. Receive an email copy of this form.
31. Email address

    This field is not part of the form submission.

32. Submit

* indicates a required field