Douglas County Household Chemical Roundup Pre-Registration Form 2012 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 at the event.

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

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.

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

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

Saturday, June 16 - Parker / Joint Services Facilities

Saturday, August 11 - Highlands Ranch / Shea Stadium

Saturday, September 15 - Castle Rock / Utiliites Department

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2. Have you ever participated in a Douglas County Roundup before?

Have you ever participated in a Douglas County Roundup before? No

Yes

Comments

*
3. How did you hear about his event? (i.e. store flyer, town newsletter, newspaper, poster, Douglas County Channel 8, TCHD website, other website, HOA newsletter, word of mouth, etc.)

Please be specific!

How did you hear about his event? (i.e. store flyer, town newsletter, newspaper, poster, Douglas County Channel 8, TCHD website, other website, HOA newsletter, word of mouth, etc.)

Please be specific!

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

What types of wastes do you plan to bring? Please check all that apply: Gas, gas/oil mixtures, other fuels

Solvents

Batteries, Household

Batteries, Automotive

Household Cleaners

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

Fluorescent light bulbs and CFLs

Lawn and Garden Chemicals

Tires, off the rim

Paint, stains, varnishes, etc.

Other (please specify)

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5. Do you have any unknown or unlabelled waste?

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 "n/a" in the email field.

Participant Information: Please use a physical address; do not use a P.O. Box. If you do not have an email address, enter "n/a" 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. Preferred method of communication:
Email is preferred by us because it is quicker and saves us money.

Preferred method of communication:
Email is preferred by us because it is quicker and saves us money. email

postal mail

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

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

Douglas County Household Chemical Roundup Pre-Registration Form 2012

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

*2. Have you ever participated in a Douglas County Roundup before?

*3. How did you hear about his event? (i.e. store flyer, town newsletter, newspaper, poster, Douglas County Channel 8, TCHD website, other website, HOA newsletter, word of mouth, etc.) Please be specific!

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

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

*6. Participant Information:Please use a physical address; do not use a P.O. Box. If you do not have an email address, enter "n/a" in the email field.

*7. Preferred method of communication: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.