Cleanup Registration/Supply Request

Cleanup Supply Request

First name

Last name

Email

Phone

Team name (if applicable)

Is this your first time requesting supplies?

Yes

No

Not sure

When do you and/or your group plan to do the cleanup?

Please tell us when you want to pick up your supplies. We request at least one week from form submission.

Please choose a time slot to pick up your supplies. They may be picked up outside our offices on the side porch.

Number of adults

Number of children

What type of cleanup are you doing?

Is this request for litter pickup in Roanoke city?

Yes

No

Brief description of cleanup location (street or park name)