ADOPT-A-HIGHWAY AGREEMENT FORM
Please Check One:   New Agreement     Renewal Agreement

The S. C. Department of Transportation and
(Adopting Group Name) recognize the need and the desirability of litter-free and visually improved highways.

The Adopt-A-Highway Program has been established for community and civic organizations as well as private businesses and industries to contribute towards the effort of maintaining cleaner and more beautiful highways.

The individual participants of the named entity are aware of the potentially hazardous nature of the work which is to be performed and have agreed to follow SCDOT’s safety guidelines and instructions and have agreed to NOT hold SCDOT or the County Adopt-A-Highway Coordinator or his / her sponsor(s) responsible for any injuries they may suffer or damages they may cause or suffer, as result of participation in the Program, as indicated by their signatures on the back of or attached to this agreement.

The South Carolina Department of Transportation recognizes the above named entity as the adopting organization for: (Roadway Name)
from to in County.

The above named entity’s volunteers accept the responsibility for picking up litter along its section of highway four (4) times a year for a period of 2 years beginning and ending .

The above mentioned entity understands the SCDOT may terminate this agreement and/or remove the Adopt-A-Highway signs bearing the Program participant’s name or acronym if, in its sole judgment, it finds and determines that the group is not meeting the terms and conditions of this agreement and of the total Program.

The above mentioned entity understands because of limited spacing on the Adopt-A-Highway signs, group names may have to be abbreviated and has written its name in the boxes below as it is to appear on the signs:

(Please allow one space after each name. Commas, colons, hyphens, etc. are counted as letters.)

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OFFICIAL SIGNATURES

Authorized Group Representative                  Additional Group Contact

_______________________________           
Signature                                                                                  Name

  
Name                                                                                           Address

        
Title                                                                                              City                                           State          Zip Code

     
 Street Address                                                                          Home Phone                              Work Phone

     
 City                                            State          Zip Code

  
 Home Phone                               Work Phone

 Email

By their signatures, the following persons have agreed to participate in four (4) litter pick­ups and abide by the Department’s guidelines and to NOT hold the Department, the County Coordinator or his / her sponsor(s) responsible for any injuries they may suffer or damages they may cause as a result of participation in the Adopt-A-Highway Program.

Signature                                                    Date      Signature                                                  Date

_____________________________________     ____________________________________

_____________________________________     _____________________________________