Name *

First Name

Last Name

Phone Number *

(###)

###

####

Planting Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Ownership of Damaged Property *

I certify that I am the owner of the property at which I am requesting a tree and that my property sustained damage from the May 27, 2019, tornados.

Permission *

I give permission to Keep America Beautiful, a nonprofit organization located at 1010 Washington Blvd, Stamford, CT 06901, and its representatives, partners, and volunteers, to enter my property for the limited purpose of participating in RETREET programming. Such participation may include, but is not limited to, surveying the property in order to locate appropriate planting sites, delivering supplies, digging holes, and planting trees.

Indemnification *

I indemnify and hold harmless Keep America Beautiful, its representatives, partners, and volunteers, from any and all liability for any damage, injury, or loss to my property resulting from activities associated with RETREET programming.

OHIO811 *

I agree to allow agents of OHIO811 to enter my property in order to mark utility lines, so as to ensure the safety of the volunteers and the proper placement of the tree, and understand that Keep America Beautiful will submit a utility locate request on my behalf.

Location *

I understand that a representative of Keep America Beautiful or one of its chosen partners will work with me to determine the best planting location for my tree(s), and that the chosen location(s) is/are not to be changed once decided upon and marked, unless safety dictates otherwise as determined by Keep America Beautiful.

Care *

I promise to water and care for my tree after it is planted, as instructed by Keep America Beautiful.

Are you willing to speak on camera about your experience with the RETREET program? *

YES

NO

Are you a veteran? *

YES

NO