Cleanup Request/Report
Coordinator Information
First Name:
Last Name:
Organization:
Type of Organization:
(None)
After-school Group
Business
Faith Based
Informal Youth Group
Neighborhood
Non-Profit
Other
School
Scout/Troop
Address:
City:
State:
AL
AK
AS
AZ
AR
CA
CO
CT
DE
DC
FM
FL
GA
GU
HI
ID
IL
IN
IA
KS
KY
LA
ME
MH
MD
MA
MI
MN
MS
MO
MT
NE
NV
NH
NJ
NM
NY
NC
ND
MP
OH
OK
OR
PW
PA
PR
RI
SC
SD
TN
TX
UT
VT
VI
VA
WA
WV
WI
WY
Zip:
Phone Number:
Email:
Confirm Email:
Cleanup Information
Event Title:
Event Description:
Date/Time of Event:
Jan
Feb
Mar
Apr
May
Jun
Jul
Aug
Sep
Oct
Nov
Dec
/
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
/
2009
2010
2011
2012
2013
2014
1
2
3
4
5
6
7
8
9
10
11
12
:
00
15
30
45
AM
PM
End Time:
1
2
3
4
5
6
7
8
9
10
11
12
:
00
15
30
45
AM
PM
Number of Volunteers:
Name/Location of Area Cleaned:
(please provide a detailed description
of the area to be cleaned. Include street
or creek name and starting/stopping point)
Is this site kid-friendly?
Type of Cleanup:
(None)
Adopt-a-Creek
Adopt-a-Steet
Waterway Cleanup
-----------------------------------------
Community Garden
Creek Restoration
Graffiti Removal
Habitat Restoration
Invasive Removal
Native Landscaping/Beautification
Neighborhood Cleanup
Roadside Cleanup
School Cleanup
Trail Maintenance
Park Cleanup
Other
Waterway:
(if applicable)
Would you like additional volunteers referred to your cleanup?
Number Needed:
Trash Collection Information
Do you need KAB to arrange to have the full trash bags collected?
(no bulky items will be allowed)
Yes
No
Closest address to where you’ll leave the full trash bags:
(exact address & zip code
needed for mapping)
Description of where you’ll leave the full trash bags:
(If you are holding a park cleanup please note that you will leave full bags by the trash cans in the park. If your cleanup is not in a park please leave the full trash bags in one pile along a street and note the closest street intersection or address.)
Supply Request
# of Bags:
# of Safety Vests:
Guidelines:
# of Gloves:
Sharps Containers:
Sunscreen:
Poison Ivy Block:
First Aid Kits:
# of Pick-up Tools:
Other:
Giveaways:
Other:
Cleanup Report - To Be Completed After Cleanup Event
Total Number of Volunteers:
Total Number of Volunteers Under 18:
Total Number of Cleanup Hours:
Total Number of Volunteer Hours (Volunteers & Cleanup Hours):
Number of Trash Bags Collected:
Number of Recycling Bags Collected:
Lbs. of Trash/Debris Collected:
Number of Miles Cleaned:
Most Unusual Object Found:
Comments:
Keep Austin Beautiful, 55 North I 35, Suite 215, Austin, TX 78702
Telephone Number:
512.391.0617
/ Fax Number:
512.391.0624
