Adopt A Highway — ALPHA PHI ALPHA FRATERNITY

Maryland Department of Transportation

State Highway Administration

Adopt-A-Highway Program

Participant Agreement

I have read and understand the Maryland Department of Transportation (MDOT) - State Highway Administration’s (SHA) Conditions for Participation in the Adopt-A-Highway (AAH) program. I have been provided with the Conditions for Participation, Safety Procedures located within the Group Application. I have read the conditions and procedures and have watched the MD SHA AAH Safety Video either at the Maintenance Shop or on YouTube at: http://www.youtube.com/watch?v=DOe0eFQYoIQ.

I understand these Conditions and Safety Procedures and agree to obey and abide by them and any other rule adopted or implemented by the SHA during my participation in the AAH.

Participants between the ages of 12 and 18 years of age will be required, to have an adult or legal guardian to agree to participation and will be fully responsible for the same safety training, and will be accompanied by said adult while working along the state highway at all times.

I am aware of the potentially hazardous nature of the work to be performed. Except to the extent any injury or damage is caused by the negligence of the State of Maryland, its officers, agents or employees, I agree to waive any claim against the State of Maryland with respect to any injury or damage arising out of my participation in the AAH program.

Small businesses and other SHA approved organizations may participate in this program. Businesses recognizing alcohol, smoking products, recreational drugs, and pornographic messages will not be permitted. Advocating, promoting, or advancing a cause such as social issues, group action, activism, political agendas or opinion, or non-family friendly messages will not be permissible under any circumstances. Recognition of tourist related facilities is acceptable.

Please complete the form below

Group Name

First Name

Last Name

Participant Name

First Name

Last Name

Shirt Size

Name of Legal Guardian or Consenting Adult (if under 18 years old):

First Name

Last Name

Participant Email

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Date

MM

DD

YYYY

MARYLAND STATE HIGHWAY ADMINISTRATION

ADOPT-A-HIGHWAY PROGRAM

SAFETY PROCEDURES

All participants must watch the MD State Highway Adopt-A-Highway Safety Video at:

http://www.youtube.com/watch?v=DOe0eFQYoIQ

Review this information at all safety training meetings, and prior to each cleaning event. Only those with a signed Participant’s Agreement may help participate.

To protect yourself and others while picking up litter:

BRING BOTH ROLLUP SIGNS AND TRASH BAGS TO THE SITE. DON’T FORGET.

1. Park all vehicles clear of the roadway; carpool to the parking area.

2. Wear a safety vest at all times; wear the vest to the work site.

3. Wear proper clothing for the weather and hard soled shoes. Avoid exposure to the sun, poisonous plants, and insect nests; long sleeve shirts and long pants are recommended.

4. Post the roll-up signs before performing any litter removal.

5. Work as a group, facing oncoming traffic at all times.

6. Provide mature supervision for youth with at least one adult at least 18 years old per 5 youth ages 12 to 17 years old. Do not allow anyone under 12 to participate.

7. Provide at least one spotter for all groups for safety and to provide warnings. The spotter is watching for oncoming safety hazards.

8. Only work during daylight hours and favorable weather conditions.

9. Maintain a working group of no more than 12 individuals.

10. Stop work in inclement weather, for all emergency vehicles until they have passed and cleared the area, or in the event of a vehicle accident in your adopted section of highway.

11. Avoid overexertion and stay well hydrated. Have a First Aid kit on site.

12. Do not remove dead animal carcasses or hazardous substances; report them to the Shop RME with your pick-up report. SHA will remove these dangerous items. Illegal items are to be reported to the police and left where they were found.

13. Stay clear of any construction sites and obey public officials.

14. Do not enter the travel portion of the roadway, tunnels, or clean on bridges/overpasses. Use crosswalks when necessary.

15. NEVER participate or allow participation by someone who is under the influence of alcohol, recreational drugs, or new medications.

16. Do not distract motorists with horseplay or abrupt, erratic movements.

REMEMBER:

YOU ARE WORKING IN A DANGEROUS ENVIRONMENT-

A PUBLIC HIGHWAY

After The Group Picks Up Litter

• REMOVE THE ROLLUP SIGNS AND TAKE THEM WITH YOU. DON’T FORGET.

• Bags must be tied securely to prevent litter from falling out and placed at one of the two recognition signs for SHA to remove.

• The Group Team Leader must notify their designated SHA contact person on the next business day, after litter pick-up is complete.

• Request additional litter bags for the next pick up if you are running low.