Group Name:             Contact Name:

Address:     City:   State: Zip:

Phone: E-Mail:

Number of Volunteers (include children and chaperons):

Location of cleanup (public areas only):    

Date of Cleanup: Rain Date: (Dates must be between March 1-May31

Date your group will pick up supplies:     (Dates must be between Feb 25-May 30)

Location that your group will pick up supplies (PLEASE CHOOSE ONLY ONE)

                                                                  Clark County Waste Management District (1602 W Main, Springfield)

                                                                  City of New Carlisle (331 S Church St, New Carlisle)

                                                                  Village of Enon (363 E Main St, Enon)