Free DT1206 - Wisconsin


File Size: 117.3 kB
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Date: April 28, 2009
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State: Wisconsin
Category: Government
Author: WisDOT
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http://www.dot.wisconsin.gov/forms/docs/dt1206.pdf

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ADOPT-A-HIGHWAY APPLICATION/PERMIT
DT1206 4/2009

Wisconsin Department of Transportation

Clear Form

Please complete this application and submit it to the appropriate Highway Region Office. We prefer that you send your completed application via e-mail. You may also send a completed application form via the U.S Postal Service. See page 3 of this application for the appropriate e-mail or postal service address. Group Name as it should appear on the sign (3 lines with 12 space maximum on each) Does your group wish installation of a sponsorship sign? Yes No

Group Name

Mailing Address

(Area Code) Fax Number (Optional)

City, State, Zip Code

(Area Code) Telephone Number Daytime

Contact Person Name

(Area Code) Telephone Number Evening

Contact e-Mail Address

Mailing Address

Approximate Number of People Participating in Each Cleanup

City, State, Zip Code

Number of Times Your Group Plans to Pick up Litter This Year - Minimum 3 Times

First enter the highway section you want to adopt. Then list alternate sections in order of preference. Contact your AAH Coordinator to confirm that your segment is available prior to submitting this application. HIGHWAY NAME/NUMBER FROM TO IN COUNTY

The WisDOT Adopt-A-Highway Safety Video is now available on the Internet!
Adopt-A-Highway Safety Video
By electronic signature below, the Group acknowledges the hazardous nature of the work and agrees to the terms and conditions stated on the page attached to this form. The Group understands there are no fees for participating in the program. This permit is valid until such time the Group notifies the Department of abandonment of their segment.
Signature of Authorized Group Representative - Must be 18 years or older Title Date

DO NOT WRITE BELOW THIS LINE PERMIT APPROVAL The Department approves this permit for the Group to participate in the Adopt-A-Highway Program for the section identified above. The Group accepts the responsibility of picking up litter on this section of highway. The Department reserves the right to modify or cancel this permit at any time. Please notify the Region Adopt-A-Highway Coordinator with any group information change.
Signature of Adopt-A-Highway Coordinator Authorized Group Representative - Must be 18 years Title The Wisconsin Department of Transportation (the "Department") and the volunteer group (the "Group") named on this application, recognize the value and the desirability of litter-free highways. Date Permit Number Group Number

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ADOPT-A-HIGHWAY PROGRAM TERMS AND CONDITIONS 1. The Group and its members are to be considered as volunteers and not as officers, employees, or agents to the Wisconsin Department of Transportation. Any injuries, claims, liabilities, suits or costs arising from Group or Group members' activities relating to this permit shall be the sole responsibility of the Group or its individual members. 2. The Group agrees to indemnify and hold harmless the Wisconsin Department of Transportation from any injury, cost, suit, liability or award arising from the issuance or exercise of this permit, or because of any adverse effect upon any person or property attributed to the works of the Group. 3. Participants in the Group agree to obey and abide by all laws and regulations relating to safety and such terms and conditions as may be required by the Department for special conditions that may exist on a particular adopted section. 4. The Group agrees to abide by terms and conditions set forth in a work plan for all freeways, interstates, and interchanges. The Group agrees to submit a completed work plan and Application before approval to begin. The Department will then complete and return the approved work plan to the address provided. 5. The Group shall pick up litter a minimum of three times a year between April 1 and November 1. The Group shall not work beyond its section limits. 6. The Group shall not pick up litter on medians, bridges, in tunnels, on overpasses or around other structures that would pose a danger. 7. The Group shall supply one adult supervisor for every 5 to 6 workers. 8. Each participant shall have reviewed the Adopt-A-Highway Safety Training Video before participation. The Group leader shall review the safety rules with all participants before proceeding to the highway segment. 9. All participants shall be at least 11 years of age or in the 6th grade and at least 16 years of age to participate and work along all freeways, interstates, and interchange segments. No other persons shall be present at the work site. 10. The Group shall work only during daylight hours and in good weather. 11. Both traffic safety signs shall be displayed properly during litter pickup. Groups shall work on only one side of the road at a time. 12. All participants shall wear safety vests. 13. When the Group encounters closed containers or items suspected to be hazardous, these items shall not be touched. Items of serious concern should be noted on the group's cleanup report. 14. The Group shall place filled trash bags at the designated pickup site and shall recycle trash as required by the Department. 15. The Group shall order required supplies and materials from the Department. 16. Unused materials and supplies furnished by the Department may be retained by the Group during the agreement period, but at the end of the period must be returned as instructed by the Department. If the Group drops from the program, all materials must be returned to the Department. 17. The Group shall not collect litter during the following holiday periods, Memorial Day extended weekend, July 3 - 5 and Labor Day extended weekend. 18. Within 24 hours of a collection, the Group shall e-mail or mail the completed Clean Up Report form DT2214, to the region office contact. See page 3 of this application for details. 19. The Group shall make arrangements for off-road parking or shuttle bus type of travel to the worksite. All vehicles at the pickup site shall be parked at the nearest cross street, if possible, or at least 3 feet from the pavement when parking on the highway. 20. The Group may keep any recyclable materials. 21. Partisan political groups (groups of people with common political opinions and purposes organized for gaining political influence, governmental control and for directing government policies) shall not be permitted to participate. 22. The Group shall notify the Department of abandonment of their segment. This permit is valid until such time the Group notifies the Department of abandonment. The Department agrees to as follows: 1. Provide safety vests, trash bags, traffic safety signs, and a safety training video. 2. Remove the filled trash bags as soon as possible after the pickup. 3. The Department reserves the right to refuse or revise acronyms of Group names when preparing signs.

Adopt-A-Highway contact information

For additional Adopt-A-Highway program information, please contact the Adopt-A-Highway Coordinator listed for the same county in which your highway segment is located. Southwest Region Madison & La Crosse (Counties: Columbia, Crawford, Dane, Dodge, Grant, Green, Iowa, Jefferson, Juneau, Lafayette, La Crosse, Monroe, Richland, Rock, Sauk and Vernon) Coordinator: Donna Sanford 2101 Wright Street Madison, WI 53704 Phone: (608) 246-3871 Fax: (608) 246-5383 E-mail: [email protected]

Southeast Region - Waukesha (Counties: Kenosha, Milwaukee, Ozaukee, Racine, Walworth, Washington and Waukesha) Coordinator: Tina Hanson 141 NW Barstow St. Waukesha, WI 53187 Phone: (262) 548-5903 Fax: (262) 548-5662 E-mail: [email protected]

Northeast Region Green Bay (Counties: Brown, Calumet, Door, Fond du Lac, Kewaunee, Manitowoc, Marinette, Oconto, Outagamie, Sheboygan and Winnebago) Coordinator: Roy Tilleman 944 Vanderperren Way Green Bay, WI 54324 Phone: (920) 492-4125 Fax: (920) 492-5711 E-mail: [email protected]

North Central Region - Rhinelander (Counties: Adams, Florence, Forest, Green Lake, Iron, Langlade, Lincoln, Marathon, Marquette, Menominee, Oneida, Portage, Price, Shawano, Vilas, Waupaca, Waushara and Wood) Coordinator: Jane Nelson 510 North Hansen Lake Road Rhinelander, WI 54501 Phone: (715) 365-5758 Fax: (715) 365-5780 E-mail: [email protected]

Northwest Region - Eau Claire (Counties: Buffalo, Chippewa, Clark, Dunn, Eau Claire, Jackson, Pepin, Pierce, St. Croix and Trempealeau) Coordinator: Joan Frey-Pospishil 718 W. Clairemont Avenue Eau Claire, WI 54701 Phone: (715) 836-2831 Fax: (715) 836-2807 E-mail: [email protected]

Northwest Region - Superior (Counties: Ashland, Barron, Bayfield, Burnett, Douglas, Polk, Rusk, Sawyer, Taylor, Washburn) Coordinator: Joseph Whirry 1701 N. 4th St. Superior, WI 54880 Statewide Bureau - Madison James Merriman P.O. Box 7986 Phone: (608) 266-3943 4802 Sheboygan Avenue, Rm 501 Fax: (608) 267-7856 Madison, WI 53707-7986 E-mail: [email protected] Phone: (715) 392-7930 Fax: (715) 392-0879 E-mail: [email protected]