2. 
   
   
4. Name*
6. Address*
8. Email*
10. Phone
12. Do you clear the Storm Drain now?*

    1. Yes
    2. No
14. Does the Storm Drain have a history of clogging with debris?*

    1. Yes
    2. No
16. Guidelines and Safety Tips:
18. 1. Never attempt to clear debris from a storm drain or culvert if there is moving water greater than knee deep.
    2. Always check for traffic before entering a roadway.
    3. Separate out any debris that is not yard waste, such as soda cans, cardboard, plastics etc., and either recycle or place in trash receptacle.
    4. Place yard debris removed from storm drain with your yard waste.
    5. The City may terminate the agreement hereunder at any time, with or without notification.
    6. I will notify the City’s Stormwater Management Database Coordinator at 386-671-8884 if I choose to no longer participate in the volunteer program.
20. I HAVE READ AND AGREE TO REGULARLY REMOVE DEBRIS FROM THE AREA AROUND MY ADOPTED STORM DRAIN IN ACCORDANCE WITH THE GUIDELINES AND SAFETY TIPS. I SHALL RELEASE AND HOLD HARMLESS THE CITY OF DAYTONA BEACH FROM AND AGAINST ALL CLAIMS, DAMAGES, LOSSES AND EXPENSES, INCLUDING BUT NOT LIMITED TO ATTORNEY'S FEES, UPON OR BY REASON OF ANY PERSONAL OR REAL PROPERTY DAMAGE WHICH MAY ARISE OUT OF PARTICIPATING IN THE ADOPT A DRAIN PROGRAM.
22. Type your full name to CONFIRM that you agree with the Terms and Conditions stated above.*
24. Date*
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25. Submit

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