1. Do you want to register for a one-off clean up or join the Adopt-a-Spot program? I want to do a one-off clean upI want to adopt a spot to keep litter-freeWe are a club with multiple sites

   All registrations will be joining the Adopt-a-Spot program.

2. Proposed date of initial clean up

Does your group require insurance?

YesNo

3. Number of people in your group*

   Please approximate if you are unsure

4. Type of organisation Please select... Individual Family Business/corporate Community/service School Other
5. Group or organisation name

   If no group go to coordinators name

6. Group Coordinator Title*
7. Group coordinator first name*
8. Group coordinator surname*
9. Street address - not P.O. Box*

   Note: for kit delivery a street address is required

10. Suburb*
11. State*
12. Post code*
13. Phone number*

    Best contact number, mobile or landline

14. Email address
15. Name of clean up site*
16. Address of clean up site
17. Suburb where site is situated
18. Local Government area this site belongs to

    Eg. City of Perth

19. Type of site Please select... Roadway Parks/waterfront River/creek Beach/coastal Public bushland Shops/malls School surrounds Rest Stop Bus stop/station Other
20. If other, please describe
21. Approximate size of the site
22. How did you hear about the Adopt a spot program? Please select... Newspaper article Friends/family Workplace School Talking Rubbish e-zine Event Advertisement Social Media Other

Yes, I wish to save resources! I can supply my own:

BagsGlovesTongs

If you have your own equipment and wish to help minimise waste and unused resources, we appreciate it! We will exclude ticked resources from your clean up kit .

23. More details or information

* denotes a required field.