Adopt-A-Street Application Name of Adopting Organization*This Name will appear on the signage Name of Adopting Organization Representative* Mailing Address of Adopting Organization* Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Name of Street to Adopt* Name of Cross Street* Name of Cross Street* Number of Block or Miles being Adopted* Upon completion of first clean-up, the City of Martinsville, Indiana will have signage prepared and placed at the beginning and ending points of the adopted street, as specified above. By singing below, the above organization agrees to at least a one-year commitment, and to maintain their adopted street a minimum once quarterly. Also, by signing below, the above organization acknowledges: The adoptee organization recognizes there is the potential hazard implicit with the work to be performed. Extreme caution must be taken to protect the safety of those members of the organization performing the clean-up. This includes, but not exclusive to, the wearing of bright colors and/or safety vests, wearing of gloves, and the wearing of protective eye coverings. The adopting organization shall assume all responsibility for and shall indemnify, defend and hold harmless the City of Martinsville, Indiana, it officers, employees, heirs, agents from and against all claims, demands, actions, judgements, settlements, and damages of every nature, degree, and kind (including direct, indirect, consequential, incidental, and punitive damages), for any injury to or death to any person, for the loss of or damage to any property whatsoever (including but not limited to property owned by or in the care, custody, or control of the City of Martinsville, Indiana, its officers, employees, or agents) arising directly or indirectly from the performance of work pursuant to this Adopt-A-Street activity. The adopting organization shall provide counsel to defend the City of Martinsville, Indiana, it officers, employees, heirs, and agents or pay the reasonable fees and court costs of the City of Martinsville, Indiana, its officers, employees, and/or agents incurred in defense of any such actions. All participants will be at least 14 years of age and those 17 and younger must be adequately supervised by one or more adults (persons aged 21 or older). Acknowledgement* I agree Name* Date* MM slash DD slash YYYY
