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4. Litter Pickup - Individual or Group

   Thank you for committing to pick up litter in Lewiston - what a great way to beautify the City of Lewiston!  Lewiston Public Works will provide latex and/or vinyl gloves, trash pickers, 5-gallon buckets, and trash liners.

6. AFTER THIS FORM/WAIVER ARE COMPLETED:
   • After completing the form, please call Al Patenaude or Megan Bates at Lewiston Public Works at 207-513-3003 Monday – Friday between 9 AM – 2 PM. 
   • Please provide three business days advance notice. The three business days provide time for request review AND time to gather materials and to communicate safety and litter pickup information, where to leave filled litter bags, and how to handle unsafe items such as needles or questionable bottles.
   • Public Works will discuss area of pickup with the individual or group point of contact making the pickup request.
8. This Form Must be Completed by EACH Individual Participating.
10. Requested Date of Litter Pickup
11. Participation Status

    1. 1) Individually Participating
    2. 2) Participating as Part of a Group
12. Minor/Adult Status

    1. Minor (Under 18)
    2. Adult (18 & Over)
14. Participant's Name
15. Parent or Guardian's NAME AND PHONE NUMBER if Participant is a Minor
17. Participant's Telephone Number
18. Participant's Email Address
20. Participant's Mailing Address (OPTIONAL)
21. Safety Guidelines May be Viewed Here
    Link Here:
23. IF IN A GROUP, WHAT IS GROUP NAME?
24. NAME OF GROUP CONTACT PERSON
26. Safety Guidelines (Check to Agree)

    1. Will wear gloves & remove safely
    2. Will use hand sanitizer when gloves are removed
    3. Wash hands with soap/warm water for at least 20 seconds at end of littler pick up
    4. Will review safety guides via online link above or in person when starting litter pickup.
27. PARTICIPATION WAIVER - PART I

    I agree to follow the COVID19 guidelines set forth for this litter pickup activity. Should I be diagnosed with COVID19 within 14 days of this activity, I will immediately notify the City of Lewiston by phone: (207) 513-3000, X3450 or by email: dispatch@lewistonmaine.gov, as well as notify my group point of contact if I participated as part of a group.

29. PARTICIPATION WAIVER - PART II
    I affirm that I have the health, physical ability, and necessary skills required to participate in this litter pick up. I have no knowledge of any condition which could endanger me or other participants. I agree to assume all risks involved in participation in this activity, including those that are not foreseeable.
30. PARTICIPATION WAIVER - PART III

    As a City of Lewiston volunteer, I hereby give full right and permission to the City of Lewiston only to take, record, use, and publish any photo, video of or including my participation without restriction and use my likeness and voice in any photography, video, or film, to include others granted permission by the City of Lewiston to use my likeness in any photography, video, or film and release. I understand that I will not be compensated for any described usage above and my likeness may be used with or without my name stated.

32. PARTICIPATION WAIVER - PART IV
    I hereby release and discharge the City of Lewiston, Maine, its agents, employees, officers, successors and assigns from all claims, demands, actions, judgments and executions which the undersigned ever had, or now has, or may have, for all personal injuries, known or unknown, and injuries to property, real or personal, caused by or arising out of the above-described activity which may result from causes beyond the control of, and without the fault or negligence of the City of Lewiston, their agents, employees, officers, successors and assigns.
34. Date of Sign-up & Agreement to All Waiver Parts
36. SIGNATURE (ELECTRONIC SIGNATURE IS PERMITTED): Signature & Submitted Form Demonstrates Agreement to All Aspects of the Above Waiver For Myself or the Minor For Whom I am Signing.

    PLEASE NOTE: Parent or Guardian Must Use His/Her Name if Participant is Under 18.

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38. 1. Receive an email copy of this form.
39. Email address

    This field is not part of the form submission.

40. Submit

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