Cleanup Supply Request and Equipment Loan Agreement Survey

1.Community Cleanup Organization Name:(Required.)

2.Name of Group Leader:(Required.)

First Name

Last Name

3.Contact Information:(Required.)

Email Address

Phone Number

4.Cleanup Event Date and Start Time(Required.)

Date / Time

Date

SuSunday

MoMonday

TuTuesday

WeWednesday

ThThursday

FrFriday

SaSaturday

Hour

Time

:

Minutes

AM/PM

5.Where will your cleanup take place?(Required.)

Location 1

Location 2

Location 3

Location 4

Location 5

6.Our cleanup will be:

public : we will allow people to participate who do not belong to our organization

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

7.What supplies will you need for your cleanup?(Required.)

Number of Pairs of Gloves (comes in a variety of sizes)

Number of Adult Size Safety Vests (comes in a variety of sizes)

Number of Trash Grabbers

Number of Garbo Grabbers

8.How many child size vests will you need?

9.How many trash bags do you expect you may need? (extras will be provided)(Required.)

10.Will you need a police escort or police assistance with this cleanup?

Yes

No

11.How many volunteers do you expect to attend your cleanup?(Required.)

12.I agree to have all volunteers sign a Volunteer Consent Agreement Form (to be provided based on my answer from the previous question), and that all participants under the age of 18 will have a custodian sign for them.(Required.)

Yes

No

13.You will be notified when your materials are available for pick up. Supplies and equipment will be available for pick up. If feasible, staff will bring your materials to the closest Horry County Recreation or Community Center available. Which location would you prefer, if this option is available?

James R. Frazier Community Center,

CB Berry Community Center, 2250 SC-179, Little River, SC 29566

North Strand Recreation Center, 120 State Hwy 57 S, Little River, SC 29566

Carolina Forest Recreation Center, 2254 Carolina Forest Blvd, Myrtle Beach, SC 29579

South Strand Recreation Center, 9650 Scipio Ln, Myrtle Beach, SC 29588

Cochran Parks and Recreation Administration Building, 2380 Oak Street, Conway, SC 29526

14.I agree to submit a Wrap Up Report at the conclusion of our cleanup.(Required.)

Yes

No

15.I hereby confirm through the submission of this form, as the cleanup group leader, that my group agrees to borrow the following listed items, equipment, and supplies from Keep Horry County Beautiful for the purposes of conducting the cleanup specified. We are aware of the requirement to receive safety training prior to conducting our cleanup.(Required.)

Certification of Supply Order and Equipment Loan Submission