Name of group/organization ________________________________________________________________

Contact Person __________________________________________________________________________

Telephone ~ (W)________________(H)_______________  email:_________________________________

 Address_________________________________________________________________________________

 City___________________________State_____________Zip_________

Number of adult volunteers__________   Number of volunteers under ages: 18_____   14_____   11_____

Number of trash bags needed ______
 

Cleanup site located in:  

Botetourt County

Roanoke County

Roanoke City

City of Salem

Town of Vinton

Address/Detailed Location of cleanup site and where filled bags will be left:      

_____________________________________________________________                                       

_____________________________________________________________ 

_____________________________________________________________

Sponsored by: The Orvis Company & Clean Valley Council

                   The Clean Valley Council thanks each of you for caring about your Valley.

  For office use only

Confirmation letter  sent:_______________

Supplies picked up _____/____/____ by _____________________

# of bags______________# of gloves__________