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Coastal Cleanup Application

Fl coastal cleanup crew forms

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8 views6 pages

Coastal Cleanup Application

Fl coastal cleanup crew forms

Uploaded by

theepaulraymond59
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PDF, TXT or read online on Scribd
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34th Annual Lakes, Rivers and

Coastal Cleanup

September 16, 2017


WAIVER

Submittal deadline: Monday, September 4, 2023, at 5:30 PM


Please mail or email or deliver the completed Participant Sign-up Sheet(s), Hold Harmless Forms, and Map to:

Citrus County Aquatic Services


1300 S Lecanto Highway
Lecanto, FL 34461
[email protected]
Need more information, call: (352) 527-7620
Thank you for making a difference in the health and quality of Citrus County’s waters!
I, __________________________________, hereinafter called the Group Leader recognize the need and the
desirability of litter-free waterways. Individuals listed on the Participant Signup Sheet will participate in the
cleanup effort on September 16, 2023.
By signing below, the Group Leader acknowledges the hazardous nature of the work and agrees to the
following:
• Any participants 17 years of age or younger, shall have adult supervision.
• All participants under age 6 MUST have one-on-one adult supervision to participate.
• The Group Leader must attend the mandatory safety meeting on Monday, September 11, 2023, at 6pm in
room 166 of the Lecanto Government Building, 3600 W. Sovereign Path, Lecanto, FL. If the Group Leader
is unable to attend the safety meeting, another group representative MUST attend.
• The Group Leader must share the safety meeting information with ALL group participants, prior to
cleanup.
• A Hold Harmless form must be signed by Group Leader and all participants. Signed forms can be
submitted with signup sheet(s) or when data cards are turned in. Group Leaders are responsible to see that
each participant signs the Hold Harmless form before participating in the Coastal Cleanup.
• Groups shall choose specific sections of waterway/shoreline for debris removal and CIRCLE on page 4
map provided.
• Participants shall submit the completed data cards to the Aquatic Services Office (address above) by
Thursday, October 12, 2023. The data is compiled and sent to the Ocean Conservancy for a national
database.
• Groups using a boat during cleanup shall abide by all laws that pertain to safe boating.

Group Leader Name: (Last) ________________________________ (First) _____________________________


Group Name: _______________________________________ Cleanup Location: _______________________
Debris Drop-off location: (circle): East or West: 1 2 3 4 5 (see details on page 4)
Mailing Address: ______________________________ City: _________________ State: _____ Zip: ________
E-Mail Address: ____________________________________________________
Preferred Contact Phone Number: _______________________ Alternate Number: _______________________
Signature of Group Leader: ______________________________________

GROUP LEADER NAME: ____________________ PAGE 1 of 6 GROUP NAME: ______________________


34th Annual Lakes, Rivers and
Coastal Cleanup

September 16, 2017

HOLD HARMLESS
(needs to be signed by each participant)
Group Leader Name: __________________, Group Name: _______________________________
Participant acknowledges the hazardous nature of the work and agrees to the following terms and conditions:
Participant agrees to indemnify, hold harmless and defend Citrus County, Florida (County), its officials and
employees from all claims, losses, damages, costs, charges, expenses, suits or actions brought against the
County as a result of any action or failure to act on the part of the participant. This includes attorney’s fees
and all costs of litigation including appellate attorney’s fees and costs as well as any judgements.
I acknowledge the fact that this program involves activities and/or conditions where injuries to may occur. In
recognition of the inherent nature of the exposures to risk associated with the Coastal Clean Up, and in
recognition of the fact that bodily injury or death may result from such activities, should they occur, the
undersigned hereby assumes the risks of all injuries to the undersigned arising out of the aforementioned
program, and forever holds harmless, releases, discharges, and agrees to indemnify Citrus County, Florida, a
political subdivision of the State of Florida, its employees, officers, commissioners and agents from any and all
claims, demands, costs, liabilities, suits or causes of action involving injuries to the undersigned resulting from,
or connected with the aforementioned activity.
Gloves and closed toe shoes must be worn by all participants. No sandals of any type will be allowed. County
can provide one-size-fits-all gloves for volunteers. However, County asks that volunteers save their gloves for
use year after year, when possible. It is also okay for participants to use their own safety gloves.

___________________________________ ________________________________
Participant Printed Name Date

________________________________
Participant Signature

Guardian if applicable:

________________________________
Signature

________________________________
Printed Name

GROUP LEADER NAME: ____________________ PAGE 2 of 6 GROUP NAME: ______________________


34th Annual Lakes, Rivers and
Coastal Cleanup

September 16, 2017


PARTICIPANT SIGNUP SHEET
Attach HOLD HARMLESS forms signed by each participant.

Group Leader Name: (Last) ________________________________ (First) _____________________________

Group Name: _____________________________________


The first 1000 participants will receive a shirt. Shirts sizes are not guaranteed. Shirt size priority is given by the
order of applications received. Possible sizes: (Youth) YS, YM, YL (Adult) S, M, L, XL, XXL, XXXL
PLEASE PRINT CLEARLY
Shirt Parental Signature (MUST for
Participants Name Phone Number
Size children 17 and younger)
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GROUP LEADER NAME: ____________________ PAGE 3 of 6 GROUP NAME: ______________________


34th Annual Lakes, Rivers and
Coastal Cleanup

September 16, 2017


Shirt Parental Signature (MUST for
Participants Name Phone Number
Size children 17 and younger)
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GROUP LEADER NAME: ____________________ PAGE 4 of 6 GROUP NAME: ______________________


34th Annual Lakes, Rivers and
Coastal Cleanup

September 16, 2017


Attach Additional Sheets if Necessary

GROUP LEADER NAME: ____________________ PAGE 5 of 6 GROUP NAME: ______________________


34th Annual Lakes, Rivers and
Coastal Cleanup

September 16, 2017


MAP

1) Circle (using any color other than black) the area(s) your group will be picking up debris.
2) Circle the Debris drop-off location(s) you plan to use.

1
2 5

4
3

4
3

West Side – Debris Drop-off Locations


1. Fort Island Park/Ramp East Side – Debris Drop-off Locations
2.
3. Chassahowitzka Camp/Ramp
4. John Brown Ramp
5. Yulee Sugar Mill

GROUP LEADER NAME: ____________________ PAGE 6 of 6 GROUP NAME: ______________________

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