86it Litter Kit Check-Out Form

86it Litter Kit Check-Out Form
Organization or School Name, if applicable
Please provide contact information for the person who will be checking out the kit. You must be 18 years of age or older to check out a kit.
Name

First NameLast Name
Email
example@example.com
Phone Number
Please enter a valid phone number.Format: 000-000-0000.
Requested Date of Litter Kit Checkout

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Requested Date of Litter Kit Return

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Address of Anticipated Pickup Location

Street Address

Street Address Line 2

CityState

ZIP Code
Estimated Number of People Participating in Cleanup
Choose Location of Litter Kit Pickup
Address Where You Want Litter Kit Delivered:

Street Address

Address Line 2

CityState

ZIP Code
Waiver of Liability

Read the complete Litter Clean-Up Liability Waiver here.
Should be Empty: