One-Time Cleanup Agreement

Community Clean Up Program - Keep Horry County Beautiful

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* 1. Community Cleanup Organization Name:

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* 2. Name of Group Leader:

First Name

Last Name

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* 3. Contact Information:

Address

City/Town

State/Province

ZIP/Postal Code

Email Address

Phone Number

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* 4. When will you hold your One-Time Cleanup?

Event Date and Start Time

Date

Time

AM/PM

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* 5. Our Cleanup event will be:

public : we will allow others from outside our group to participate

private : only members from our group will be able to participate

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* 6. We would like for Keep Horry County Beautiful to advertise our event on Facebook (we can advertise your event as private or public, the purpose of putting these events on Facebook to show off our partners and their commitment to keeping Horry County litter free).

Yes

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* 7. Please agree to each of the following by selecting the box.

Our participants shall attend a safety briefing by group leader before the start of the cleanup.

If youth groups are involved in the cleanup adult supervision is required at all times. Participants under 16 must have parental or legal guardian consent to participate.

We will not wear music headsets, which could interfere with hearing traffic. We will not wear hats that could obscure our vision and keep us from seeing an approaching hazard.

We agree that alcoholic beverages and intoxicated participants are prohibited from participating.

We will work together as a group and walk facing oncoming traffic. Work one side of the road at a time.

Everyone participating in the cleanup will wear orange or yellow safety vests at all times. Long sleeves, long pants, leather shoes or boots, gloves and eye protection are recommended. KHCB provides safety vests. KHCB provides gloves on request.

Volunteers that are under the care of physician and are taking prescribed medication that alters normal reactions, will not participate in cleanup events.

Work will only be performed during daylight hours and not during inclement weather.

We will not bring knives, manchettes or other such tools that could cause accidental injuries.

We will be alert and ready to react to traffic.

We will not pick up litter from the roadway. We will stay at least 5 feet away from the edge of the road.

We will not engage in horseplay.

We will not try to handle hazardous litter, such as: discarded syringes/needed, car batteries, and any kind of hazardous materials. We will inform KHCB and/or Law Enforcement to let them handle these kinds of issues.

We will be careful handling broken glass. We will be careful not to step or kneel in areas where there might be hidden or broken glass.

We will watch out for bees, wasps, fire ants, snakes, poisonous plants and other potential natural hazards.

We will stay off of steep slopes, culverts, ditches, highway construction and maintenance areas.

In warm weather we will take frequent drinks of water, frequent breaks and take steps to prevent sunburn.

We will not try to compress trash into the bags, as sharp objects could cause injury.

We will have a first aide kit and cell phone.

We will check in with our group leader before allowing participants to leave.

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* 8. I understand that I am volunteering to participate in this event at my own risk. Further, I agree to follow the above stated Community Cleanup Safety Guidelines, and that I shall NOT hold the Keep Horry County Beautiful Committee, the Community Cleanup organization as a host of the cleanup event, or any other board, committee, staff member or elected official who is part of Horry County Government responsible for any incurred damages, personal injuries or death(s) that may result from participating in the Community Cleanup Program and the specific cleanup event. I understand that upon picking up my cleanup supplies, I will need to sign a physical copy of this Assumption of Risk and Wavier Agreement.

Certification of Assumption of Risk and Waiver Agreement

Date

Time

AM/PM