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Land Stewards Program Registration
Home
Programs
Land Stewards Adoptions
Land Stewards Program Registration
Step
1
of
3
33%
I have read and understand the KPB Adoption Program Guidelines
(Required)
Program guidelines available here
Yes
I have read and understand the KPB Adoption Program Volunteer Safety Guidelines and viewed the Adoption Program video.
(Required)
Safety guidelines available here
View the video
here
or on the
main Land Steward Program page
.
Yes
PRIMARY CONTACT INFORMATION
(must be 18 years of age)
Name
(Required)
First
Last
Organization affiliation (if any)
Title (if applicable)
Address
(Required)
Street Address
Address Line 2
City
State
ZIP / Postal Code
Phone (home)
(Required)
Phone (work)
(Required)
Email
(Required)
Enter Email
Confirm Email
ROAD AND AREA ADOPTION INFORMATION
Type of area
(Required)
Select One
Roadway
Greenway (trail, waterway, pathway, park)
City block
Parking lot
Vacant lot
Community
Other
Name of road/area to be adopted
(Required)
Is the road/area safe for volunteers?
(Required)
Yes
No
Name of Municipality
(Required)
Name of County
(Required)
If the adoption will be in a state park or forest, please list its name.
Please list landmarks identifying the beginning and end points of the adoption.
(Required)
Overall length of road, trail or path
(Required)
(miles and tenth of miles)
If adoption will be on private property, has written permission been obtained?
(Required)
Private roads are not eligible for adoption unless they are open for public use.
Yes
No
Not on private land
Please upload a permission letter from the property owner.
If unable to upload letter, please email to
Stephanie Larson
Max. file size: 128 MB.
ADDITIONAL INFO FOR COMMUNITY ADOPTIONS
This section is only for municipalities who are registering for a community adoption
Are you a representative for a municipality who is registering an adoption for a community?
(Required)
Yes
No
Please upload a letter of support from the local municipality
If unable to upload letter, please email to
Stephanie Larson
Max. file size: 128 MB.
Is the community in compliance with Act 101?
(Required)
(Communities with over 10,000 residents and densely populated municipalities having between 5,000 and 10,000 residents are required to have recycling programs.)
Yes
No
Sign set includes:
one 30" x 30" Keep Pennsylvania Beautiful Sign
One 24" x 12" sign recognizing the adopters
Do you wish to purchase additional sets of signs?
(Required)
KPB provides one set of signs free of charge.
Additional sets can be purchased for $133. If additional sets are requested, payment methods will be discussed once adoption location is approved by KPB and the maintainer of the property. Payment must be received before sign order is placed.
Yes
No
Recognition sign to read:
(Required)
KPB may edit adoption sign wording requests, but will work closely with the adopter to agree on final wording.
Location to ship signs:
Signs will be shipped to the municipality for installation.
Please provide the address and name of a contact person.
Signs can not be shipped to a post office box.
Municipal Contact Name
(Required)
First
Last
Municipal Shipping Address
(Required)
Street Address
Address Line 2
City
State / Province / Region
ZIP / Postal Code
Signature
Signature
(Required)
Keep Pennsylvania Beautiful reserves the right to revoke or refuse an adoption.
By typing your name below you are signing the application and verifying that the primary contact is at least 18 years of age. The primary contact agrees to:
Make safety a top priority and review the
KPB safety guidelines
and
adoption video
with all adoption cleanup participants.
Assure all cleanup volunteers sign a liability waiver and parental consent forms for participants under the age of 18. Please contact
Stephanie Larson
for these forms. Completed forms can be uploaded at the time of reporting.
Secure permission to enter if adoption is on private property.
Coordinate two cleanups per year.
Report your results within 2 weeks of each cleanup.
Provide written notice to Keep Pennsylvania Beautiful in the event that he or she wishes to terminate the adoption.
In consideration for the opportunity to engage in volunteer work through PA CleanWays d/b/a Keep Pennsylvania Beautiful (KPB), I agree for myself, my executors, administrators, heirs, successors and assigns to: (A) waive, release or discharge the following persons and entities from any and all liability for death, disability, personal injury, property damage, property theft or actions of any kind which may hereafter occur to me: KPB, its parent and affiliates, their directors, officers, employees, volunteers, representatives, agents, event holders and landowners whose facilities are being used or whose property is being cleaned (collectively the ‘Released Parties’); and (B) indemnify and hold harmless the Released Parties from any and all liability, claims, actions, suits, procedures, costs, damages, fines, penalties and expenses, including but not limited to attorney’s fees, which arise in connection with my participation in the volunteer activities, without limit and whether caused by the acts or omissions of the Released Parties.
Date
(Required)
MM slash DD slash YYYY
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