Living Lands and Waters -Xstream Cleanup in Lousiville, KY

PLEASE PRINT THE GENERAL LIABILITY RELEASE FORM ABOVE
READ, SIGN AND BRING TO THE EVENT TO VOLUNTEER

*Denotes a required field.

*Name:
*Email:
Alternate Email:
*Address:
*City:
*State:
*Zip:
*Primary Phone:
Secondary Phone:
Work Phone:
Xstream Sites
Group Leader:	Yes No
	If yes, how many group members will be joining you? (PLEASE INCLUDE YOURSELF, THE GROUP LEADER, AS PART OF THIS NUMBER)
Organization/ Affiliation:
Comments:
	* Type in the text from the left:

FOR MORE INFORMATION:

Shanon Reineke
shanon@livinglandsandwaters.org
(309)236-5627

Greg Boll Photography,
Photographer for LL&W