Adopt-A-Street Application Form

* mandatory field

*Are you volunteering as

*I understand that the Primary Applicant/Group Contact must be over 16 years of age.

Contact Information

*Preferred contact method


Organization Alternate Contact

Only complete the Organization Alternate Contact if you are part of an Organization.

Adopt-A-Street Information

Please be as detailed as possible.
*I agree to commit to this program for a minimum of one year.
*Do you wish to be publicly recognized?

example: “The Smith Family”
*By checking this box, I acknowledge that I understand and agree to the terms outlined in Coquitlam’s Adopt-a-Street Program Agreement Form.
*By checking this box, I acknowledge that I understand and agree to the terms outlined in Coquitlam’s Adopt-a-Street Program Release & Waiver Agreement.
*By checking this box, I acknowledge that I have read and agree to abide by Coquitlam’s Adopt-a-Street Program Safety Checklist.
*I agree to receive periodic notifications regarding the Adopt-A-Street Program.

*I understand that I am responsible to ensure that Adopt-A-Street has my current and accurate contact information, and that failure to do so may result being removed from the program at the coordinator’s discretion.

By checking "I consent" you are consenting to the voluntary collection and use of your personal information in accordance with Section 26(d) of the Freedom of Information and Protection of Privacy Act (the “Act”). The information provided by you will be used solely for the purposes of the Adopt-A-Street Program and will not be used for any other purpose. If you have any questions about the collection, storage, correction and/or use of your personal information please contact Tara Pastora, 500 Mariner Way at 604-927-6205.
 
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