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2. Adopt-A-Spot Program Agreement
4. In order to enhance the environment and the appearance of our community, the applicant(s) undersigned, request permission to Adopt-A-Spot at the following location (address or boundary description):
6. Property Description:
8. Property Owner Name
9. Property Owner Phone #
11. Property Owner Address
13. Property Owner Signature
    I authorize approval of this Adopt-A-Spot agreement with the adopting organization identified below.
14. Date
    Date
16. Said work will be performed under and in accordance with James City County terms attached hereto and incorporated herein by reference.
18. Applicants with whom agreements are signed shall at all times indemnify and hold harmless James City County, its employees, the Commonwealth and its employees, their officials or agents, from responsibility, damage, injury, or liability arising from the exercise of the privileges granted under this agreement.
20. This agreement may be terminated by James City County at any time that the applicants do not comply with this agreement or at any time the applicants’ work effort is considered unsafe. The County reserves the right to revise or discontinue this program at any time.
22. Applicant(s) hereby assume all risk of damage or injury resulting from the activities performed hereunder, and recognize that certain risks are inherent in litter pickup, especially in areas open to the public.
24. It is understood that the applicant is not an employee or volunteer of the County while participating in the Adopt-A-Spot program. As such, James City County is not providing any worker’s compensation insurance; general liability; or automobile insurance or uninsured/underinsured motorist insurance coverage, for acts or omissions of applicant while engaged in any activities arising out of or related to this Adopt-A-Spot agreement and program.
26. It is further understood that the County will not defend, hold harmless, or indemnify the applicant for any claims of loss, injury, death, or damage arising out of or related to this Adopt-A-Spot agreement and program.
28. Name of adopting organization or individual (individuals must be at least 18 years of age)
30. Primary Contact
31. Title
33. Address
35. Phone #
36. Email
38. Primary Contact Signature
    On behalf of the organization or individual listed above I agree with the terms of the Adopt-A-Spot Program.
39. Date
    Date
41. Exact name and spelling to be printed on sign
43. Preference for add-on sign

    1. STOP LITTERING...Virginia is too good to waste
    2. HAVE PRIDE DO NOT LITTER
    3. *Other
44. *Other suggestion
48. FOR OFFICE USE ONLY
50. The undersigned is the owner, agent, or government official or representative who has the legal authority to hereby give permission for the property location names in the aforesaid agreement to be involved in the designated Adopt-A-Spot program as administered by James City County.
53. Permission is hereby given to perform the work described insofar as James City County has the right, power, and authority under this agreement:
Leave This Blank:


56. 1. Receive an email copy of this form.
57. Email address

    This field is not part of the form submission.

58. Submit Submit and Print

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