Trash 4 Cash Registration Form

Once form is submitted that will be your confirmation the cleanup is scheduled unless we contact you otherwise.

Today's Date Today's Date / MM / DD YYYY
Date of Cleanup Date of Cleanup / MM / DD YYYY
Name of Group
Contact Person Contact Person First Last
Phone Phone - ### - ### ####
Email
Address Address
Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country
Non-Profit Groups Tax ID (Mandatory)
Number of Volunteers
Ages (must be at least 8 Years)
You must make an appointment to pick up your supplies for your cleanup.
Please email kmb@keepmidlandbeautiful.org or call 432-688-7745 the Monday prior to your cleanup date to make the appointment.

You must make an appointment to pick up your supplies for your cleanup.
Please email kmb@keepmidlandbeautiful.org or call 432-688-7745 the Monday prior to your cleanup date to make the appointment. I agree
Special Requests
THE RELEASE FORM MUST BE SUBMITTED BEFORE PARTICIPATION IN THE EVENT CAN BE ALLOWED.
In consideration of Keep Midland Beautiful’s acceptance of this entry in the above Project, we, the undersigned, individually and on behalf of our minor child/children, administrators and assigns, forever release and discharge any and all rights, demands, claims and causes of suite or action, known or unknown, whether arising now or in the future that we, individually and our minor child/children may have against Keep Midland Beautiful, its officers, agents, employees, and volunteers, and all other property owners and any other participating sponsors, as the officers, employees and agents of such parties for any and all injuries, including death and property damage, in any manner arising or resulting from participation in said Project. We attest and verify that we have full knowledge of the risks involved in the Project, that we individually assume those risks on behalf of ourselves and our minor children, and that we will individually without limitations, assume and pay any medical and/or emergency expenses in the event of an accident, injury, illness or other incapacity, regardless of whether we have authorized such expenses. Further, we state that we have carefully read this Release, know the contents of the Release, and sign this Release of our own free will.

THE RELEASE FORM MUST BE SUBMITTED BEFORE PARTICIPATION IN THE EVENT CAN BE ALLOWED.
In consideration of Keep Midland Beautiful’s acceptance of this entry in the above Project, we, the undersigned, individually and on behalf of our minor child/children, administrators and assigns, forever release and discharge any and all rights, demands, claims and causes of suite or action, known or unknown, whether arising now or in the future that we, individually and our minor child/children may have against Keep Midland Beautiful, its officers, agents, employees, and volunteers, and all other property owners and any other participating sponsors, as the officers, employees and agents of such parties for any and all injuries, including death and property damage, in any manner arising or resulting from participation in said Project. We attest and verify that we have full knowledge of the risks involved in the Project, that we individually assume those risks on behalf of ourselves and our minor children, and that we will individually without limitations, assume and pay any medical and/or emergency expenses in the event of an accident, injury, illness or other incapacity, regardless of whether we have authorized such expenses. Further, we state that we have carefully read this Release, know the contents of the Release, and sign this Release of our own free will. I have read & accept the terms of the Liability statement
I hereby grant the Keep Midland Beautiful, Public and Media Relations Office, the right to photograph members, employees, officers, and/or any agents participating in Keep Midland Beautiful events and to use or authorize the use of the photo for promotional purposes as related to Keep Midland Beautiful produced publications and materials and external publications and materials where Keep Midland Beautiful would release use of the photo to support information about Keep Midland Beautiful programs and services.
I hereby acknowledge that no fee is payable by Keep Midland Beautiful, Public and Media Relations Office, for this appearance or resulting distribution, and that the provisions of this release are legally binding.

I hereby grant the Keep Midland Beautiful, Public and Media Relations Office, the right to photograph members, employees, officers, and/or any agents participating in Keep Midland Beautiful events and to use or authorize the use of the photo for promotional purposes as related to Keep Midland Beautiful produced publications and materials and external publications and materials where Keep Midland Beautiful would release use of the photo to support information about Keep Midland Beautiful programs and services.
I hereby acknowledge that no fee is payable by Keep Midland Beautiful, Public and Media Relations Office, for this appearance or resulting distribution, and that the provisions of this release are legally binding.
I agree I do not agree
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