Adams County Household Chemical Roundup Pre-Registration Form 2016 Survey

Thank you for registering for the Houshold Chemical Roundup ahead of time. Pre-registration provides you with an alternative to registering in line at the Roundup and helps us serve you better.

Pre-registration is optional. If you don't pre-register, you can still show up during the hours of operation and register on site.

The Adams County Household Chemical Roundups are for Adams County residents only.

Please Note: The Cities of Aurora, Northglenn, and Westminster are not participating in these events. Aurora, Northglenn, and Westminster residents CANNOT bring waste to the Roundup events this year. (This does not affect those residents of Unincorporated Adams County that have Aurora, Northglenn, or Westminster addresses, as anyone in Unincorporated Adams County is eligible to attend.) For more information, residents of Northglenn should call (303) 450-4004; residents of Aurora should call (303) 915-8924; and residents of Westminster should call (303) 706-3362.

Online Registration Form Instructions:

Answer all of the questions on each page, then click the " Next >> " button at the bottom of the page to go to continue. You may go back at any time by clicking on the " << Prev " ("previous") button.

On the last page, click the "Done >>" button to submit the your information and return to the Tri-County Health Department Household Chemical Roundup website.

Verification that you have succesfully pre-registered and information about the event will be sent to you by email or postal mail about a week before the event, along with a map and additional information.

Question Title

* 1. Which Household Chemical Roundup will you attend?
Note: the deadline to pre-register is the Monday before each event
The event operates from 9:00 a.m. to 3:00 p.m.

Saturday, May 7 - Hyland Hills Water World / Federal Heights

Saturday, September 17 - Thornton IMC Facility / Thornton

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* 2. Have you ever participated in an Adams County Roundup before?

Yes

Other (please specify)

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* 3. How did you hear about this event? (i.e. flyer, poster, Tri-County Health Department website, city or county website, city newsletter, HOA newsletter, newspaper, word of mouth, etc.) Please be specific!

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* 4. What types of wastes do you plan to bring? Please check all that apply:

Automotive fluids (motor oil, antifreeze, brake fluid, etc.)

Paint, stains, varnishes, etc.

Fluorescent light bulbs and CFLs

Tires, off the rim

Batteries, Automotive

Batteries, Household

Lawn and Garden Chemicals

Household Cleaners

Items containing mercury

Solvents

Gas, gas/oil mixtures, other fuels

Scrap metal

Other (please specify)

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* 5. Do you have any unknown or unlabelled waste?

Yes

I don't know

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* 6. Participant Information:
Please use a physical address; do not use a P.O. Box. If you do not have an email address, enter "none" in the email field.

First Name

Last Name

Street Address

City

Zipcode

Email address
Enter "none" if no email

Daytime phone number:
(xxx) xxx-xxx

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* 7. My preferred method of communication is via:
Email is preferred by us because it is quicker and saves us money.

phone

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* 1. Which Household Chemical Roundup will you attend? Note: the deadline to pre-register is the Monday before each eventThe event operates from 9:00 a.m. to 3:00 p.m.

Question Title

* 2. Have you ever participated in an Adams County Roundup before?

Question Title

* 3. How did you hear about this event? (i.e. flyer, poster, Tri-County Health Department website, city or county website, city newsletter, HOA newsletter, newspaper, word of mouth, etc.) Please be specific!

Question Title

* 4. What types of wastes do you plan to bring? Please check all that apply:

Question Title

* 5. Do you have any unknown or unlabelled waste?

Question Title

* 6. Participant Information:Please use a physical address; do not use a P.O. Box. If you do not have an email address, enter "none" in the email field.

Question Title

* 7. My preferred method of communication is via:Email is preferred by us because it is quicker and saves us money.

Question Title

* 8. Questions/Comments: Note: due to time constraints, we may not respond to all questions/comments.

* 1. Which Household Chemical Roundup will you attend?
Note: the deadline to pre-register is the Monday before each event
The event operates from 9:00 a.m. to 3:00 p.m.

* 6. Participant Information:
Please use a physical address; do not use a P.O. Box. If you do not have an email address, enter "none" in the email field.

* 7. My preferred method of communication is via:
Email is preferred by us because it is quicker and saves us money.

* 8. Questions/Comments:
Note: due to time constraints, we may not respond to all questions/comments.