Form Builder

Required fields are marked with asterisks (*)

2023 Roadside Cleanup Registration and Commitment Form

Please ensure all sections of this form are completed.

Deadline for Submission: March 24, 2023 @ 4:30 pm

The safety of participants is our primary concern, so we kindly ask you review the Cleanup Safety Plan you will be required to follow in advance of applying.

Group Name

Number of Participants

Preferred Date of Cleanup

Contact Name

Phone Number

Email Address

Mailing address of organization to send payment (cheque will be issued to group)

Please indicate your first, second, and third choice for cleanup zone below. You are not guaranteed to receive the zones you select. You may be offered other available zones or no zones at all.

Zone Map Number that is your FIRST CHOICE

Zone Map Number that is your SECOND CHOICE

Zone Map Number that is your THIRD CHOICE

Are you able to take the collected waste to the closest landfill or designated bin?

Yes

Brief Description of fundraising event and what the funds are being used for

For inquiries please contact Public Works at 780-532-7393

Please pick up supplies 2-3 days prior to your cleanup date at the Clairmont Centre for Recycling and Waste Management at 724065 RGE RD 63. Hours are Monday-Saturday 8 am - 6 pm.

Following the selection process, all applicants will be contacted.

Signature of Group Representative

Clear

By completing this form, your organization authorizes the County of Grande Prairie to take and/or use photos/pictures in any publications of or for the County, or its affiliates. Your organization is aware that it will not be paid for the photos/pictures or their use and will not receive payment if the pictures/photos appear in any publications or circumstances. Your organization consents to the use or reproduction of the pictures or images as provided for the Roadside Cleanup Program.

Protection of Privacy - Personal information is collected in accordance with Section 33(c) of the Alberta Freedom of Information and Protection of Privacy Act (the FOIP Act) and will be protected under Part 2 of that Act. It will be used for the purposes of administering the program or service for which the information is collected. Should you require further information about collection, use and disclosure of personal information, please contact the FOIP Coordinator at foip@countygp.ab.ca or call 780-532-9722.