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2. ADOPTING GROUP CONTACT INFORMATION
4. Primary Contact Person*
5. Email Address*
7. Address
9. City
10. State
11. Zip Code
13. Phone Number*
15. Secondary Contact Person*
16. Email Address
18. Address
20. City
21. State
22. Zip Code
24. Phone Number*
26. Name and location of adopted street(s)*
28. Name/Organization for the street sign:*
    Please type exactly as to be displayed on street sign.
30. Number of participants (for supplies):*
32. Program Requirements
    Program Information and Requirements
34. I understand that during my participation in the Adopt-A-Street Program, I am subject to the rules and regulations of the Village’s Public Works Division. I do hereby agree to release, indemnify and hold harmless the Village of Clemmons, its agents, officers and employees and volunteers from any and all claims, liabilities, demands, damages, actions or causes of action of any kind or character (including, without limitation, attorney's fees, costs and expenses) that may arise in any manner by reason of death, injury, damage to my person or property or both as a result of my participation in the Adopt-A-Street Program. By submitting this form, I agree to abide by all of the program guidelines.*

    1. Agree
    2. DO NOT Agree
Leave This Blank:


36. 1. Receive an email copy of this form.
37. Email address

    This field is not part of the form submission.

38. Submit

* indicates a required field