Please complete all fields and then click the "Submit" button.

Do not use the 'Enter' key until you have completed the form. Any field with an Asterisk (*) is required

If you are an Adopter or Litter Free School Zone and need cleanup supplies, contact Stephanie Larson slarson@keeppabeautiful.org

Are you using a Paid Contractor?

List the paid contractor(s) you will be using?

If you are using paid contractors, and if you are a KPB affiliate, please send a copy of the contractor's W-9, General Liability Insurance Certificate, and Worker's Comp Insurance Certificate to the home office prior to the event. This information is critical for insurance audit purposes and pertains to KPB affiliates only.
If the W-9, General Liability Insurance Certificate, and Worker's Comp Insurance Certificate are NOT received in the home office prior to the event date, your event will not be covered by PA CleanWays liability insurance.

Any In kind donations?

How Were You Referred?

Group Details

Group Name

Event Contact Person First Name

Last Name

Phone

Confirm Email

Contact Address

Address

Address 2

City

State

Zip

Event Information

Event Type

Event Details

Event Name

Event Website

How many years have you held events?

Estimated # of Volunteers

When is Your Event?

Starting Date & Time

Event Rain Date & Time

How long is your event?

Where is Your Event?

Event Location / Address (limit 255 characters)

Is your event on any public use land (state park, state forest, game land, local park, waterway, open public space)?

County Event will be held in:

Nearest Municipality:

Addtional Info

Is this a private event? (This will hide the event on the calendar)

Notes for your Event (These will display on our calendar)

Event Registration Form