Adopt-A-Street Quarterly Report

2. Adopt-a-Street Partner*

4. Street/ area*

6. Date of pick up*
   Date of pick up

7. Person Submitting*

9. Telephone*

10. Email*

12. Number of volunteers *

13. Hours each*

15. Number of volunteers under 18*

16. Over 18*

18. Number of bags of trash collected*

19. Number of bags of recycle materials collected*

21. Rate the Cleanliness of your street: Before Clean Up*

    Using the following scale: 1 = No litter, 2 = Lightly littered, 3 = Littered, 4 = Extremely littered

22. After Clean Up*

24. Comments/ most interesting item found:

26. Thank you for helping Keep Southlake Beautiful!
    Please email or mail us photos of your group during the cleanup. Call (817) 748-8019 or email parksandrec@ci.southlake.tx.us for more information.

    Please email or mail us photos of your group during the cleanup. Call (817) 748-8019 or email parksandrec@ci.southlake.tx.us for more information.

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28. 1. Receive an email copy of this form.
29. Email address

    This field is not part of the form submission.

30. Submit

* indicates a required field