2. 
3. Earth Day Neighborhood Clean Up

   Celebrate Earth Day by gathering with your neighbors and cleaning up your community! The Parks and Recreation Department is looking for residents to organize an Earth Day Clean-up event at one of the following areas: park, pond, rain garden, storm drain, or drainage ditch. You select the date, time, and project….we provide the supplies! Select a date anytime between April 17 and May 15.

5. Name*
6. Email Address*
8. Address*
10. City*
11. State*
12. Zip Code*
14. Phone Number*
16. Type of group:*

    1. Scout group
    2. Church group
    3. Service group
    4. Open to all my neighbors
17. If this is an organized group, please list the name here:
19. I am interested in cleaning up:*

    1. Park
    2. Pond
    3. Ditch
    4. Rain Garden
    5. Storm Drain
21. Name of park or location of pond, ditch, rain garden, or storm drain:
23. Date and time of event:
    Date and time of event: Start Date

    Date and time of event: Start Time

    —

    Date and time of event: End Date

    Date and time of event: End Time
25. Please provide our group with the following supplies:

    1. Garbage and yard waste bags
27. Do you have any additional questions?
29. CONSENT TO RELEASE OF INFORMATION & RELEASE OF LIABILITY
    In consideration of your accepting this application, I authorize the City of Blaine to disclose to the City’s insurer, attorney, staff, coaches, participants and other personnel involved in this program the following information: name, address and telephone number. This information shall be used for the purpose of program administration. This consent to release information shall expire one year from the date of execution. I understand that the records are protected under the state and federal privacy regulations. I also understand that I may cancel this consent by a writing to that effect at any time prior to the information being released. I give my consent to use any photograph or video tape taken of myself for future promotional or marketing materials. In consideration of the City providing the registered activities, I agree to not hold the City liable for any claim resulting from participation in any such activity, including claims for injuries, death and resulting attorney fees. The completion of your registration signifies your acceptance of this consent.
31. By checking this box, you agree to the waiver and liability clause above. *

    1. I agree
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

* indicates a required field