Form Center

2. GROUP/ORGANIZATION
4. Group Name*
6. Street Address*
8. City*
9. State*
10. Zip Code*
12. Group Leader Name*
14. Type of Group*

    1. Civic Group
    2. Not for Profit Group
    3. Private Enterprise/Commercial
15. Application Status*

    1. First Application
    2. Renewal Application

    (Check One)

17. Approximate No. of Participants for Litter Pickup*
18. Number of Adult Supervisors*

    (If Participants are between 10 and 18 years old.)

20. Name/Acronym for Sign *

    Name/Acronym requested to be on Adopt-a-Park sign.  No logos or slogans will be allowed. Limit of 17 characters per line, limit two lines and leave space between words. 

22. GROUP COORDINATOR
24. Name*
26. Street Address*
28. City *
29. State*
30. Zip Code*
32. Email*
33. Phone Number*
35. FIRST CHOICE: Park to be Adopted*

    Park Name 

37. SECOND CHOICE: Park to be Adopted*

    Park Name

39. Certification*

    1. I Agree

    By checking this box, I hereby certify that the above information is correct and my Group/Organization agrees to conform to the requirements of the Village of Libertyville Adopt-a-Park Program.

    Your Adopt-a-Park application will be sent to the Director of Public Works for final approval.   

    Public Works staff will contact you when the application has been approved.    Please contact Assistant Director Laura Ditanto at lditanto@libertyville.com with questions. 

    
    

43. INTERNAL USE ONLY
45. Signature

    Director of Public Works 

46. Date
Leave This Blank:


47. 1. Receive an email copy of this form.
48. Email address

    This field is not part of the form submission.

49. Submit

* indicates a required field