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2. Green Bucket Brigade Registration

   Thank you for your interest in the City of Norfolk’s Green Bucket Brigade, an invaluable part of our City’s litter reduction and prevention efforts! This program is currently open to businesses, local organizations, civic leagues, faith groups, etc. If you are an individual interested in the program, please contact knb@norfolk.gov for information on how you may still get involved. 

   
   

4. First Name*
5. Last Name*
6. Email*
8. Phone*
9. Zip*
11. Who are you requesting a Green Bucket for? *

    1. Business
    2. Faith Group
    3. School
    4. Club/Organization
    5. Other
13. Organization Name *
15. If other, who are you requesting a Green Bucket for?
17. Address*

    Please provide the address of where the bucket will be kept. 

19. As a member of the Green Bucket Brigade, I agree to comply with the following requirements by checking each box below: *

    1. I agree to report the cleanup information monthly to Keep Norfolk Beautiful.
    2. Call Keep Norfolk Beautiful at 757-441-1347 or email knb@norfolk.gov for bulk waste pickup, if needed.
    3. Conduct clean-ups in compliance with KNB’s Safety Procedures.
    4. Inform all participants, if applicable, of the safety guidelines prior to each clean-up and have each sign the Attendance Sheet/Safety Waiver.
    5. Notify KNB if I no longer wish to participate in the program, and I agree to return all supplies within a week of ending my participation in the program
21. Certification and Acknowledgement of Risks
    I hereby certify that all statements made in this application are true and correct to the best of my knowledge, and I authorize investigation of all matters contained in this application or data pertinent to my volunteering. I acknowledge that any false statements or misrepresentation on this application will be cause for refusal of placement or immediate dismissal. I understand and agree that in the performance of voluntary services, I am not a City of Norfolk employee and shall have no rights to wages or benefits and no promise, expressed or implied, of consideration for future employment. I agree to indemnify and hold the City of Norfolk, its employees and contractors harmless from any and all liability for any injury that I might incur arising out of or in any way connected to my participation in this program. I also agree to grant full permission to the City of Norfolk to use my name and any photographs, video or recordings for any purpose whatsoever without many obligation, liability or compensation to me. Volunteers are not covered under the City of Norfolk Worker’s Compensation Plan. Therefore, it is recommended volunteers have their own medical insurance coverage. If a serious incident occurred a legal claim could be presented and an investigation into negligence would take place. For more information refer to the City of Norfolk City, Code Section 2-155, Appendix C and/or contact the Human Resources Department at 757-664-4056.
23. Signature*
    By signing the above you agree to the conditions of the Green Bucket Brigade, and attest that you are at least 18 years or older.
24. Date*
    Date
Leave This Blank:


26. 1. Receive an email copy of this form.
27. Email address

    This field is not part of the form submission.

28. Submit

* indicates a required field