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2. 
4. Name of Adopting Organization*
6. Number of stream clean-ups per year (two minimum)*
   -- Select One --234Other
7. Creek Segment Desired

   If your group knows what segment of creek you want to adopt, please list/describe it here.  

9. Name (Primary Contact)*
10. Email Address*
12. Address*
14. City*
15. State*
16. Zip Code*
18. Phone Number*
19. Approximate Number in Clean Up Group*

    This number may vary, but please let us know how many people you anticipate having at your clean ups, so we can get you the proper amount of gear.

20. Age Range *

    What is the age range of participants in your group?

22. First Name (Secondary Contact)*
23. Last Name*
25. Phone Number*
26. Email Address*
28. Agreement

    The work will be performed under and in accordance with the Town of Fort Mill Stormwater Department's Adopt-a-Stream General Program Conditions and Safety Guidelines (both on website and incorporated herein by reference).

    Applicants to whom an Adopt-a-Stream Program Designation and Agreement are issued shall at all times indemnify and save harmless the Town of Fort Mill and all of its 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 Town of Fort Mill at any time.  The Town of Fort Mill reserves the right to revise or discontinue the Adopt-a-Stream Program at any time. 

30. As a designated representative of the group listed above, I have read, understand and shall comply with the Adopt-a-Stream General Program Conditions and Safety Guidelines regarding participation in the program*

    1. I agree
32. Electronic Signature*

    Type your name and this will act as your electronic signature 

33. Date*
    Date
Leave This Blank:


35. 1. Receive an email copy of this form.
36. Email address

    This field is not part of the form submission.

37. Submit Submit and Print

* indicates a required field