Form Center

Neighborhood Clean Up Kit Request

2. Neighborhood Clean Up Kit
   Neighborhood clean up kits contain everything you may need to pick up litter in your neighborhood. Reserving a neighborhood clean up kit is easy! Simply fill out the form below and someone from the City's Neighborhoods Team will promptly follow up on the request.

   Neighborhood clean up kits contain everything you may need to pick up litter in your neighborhood. Reserving a neighborhood clean up kit is easy! Simply fill out the form below and someone from the City's Neighborhoods Team will promptly follow up on the request.

4. Clean Up Results - Reporting Form
   We ask that you please track the number of volunteers, hours worked and number of filled trash bags collected by filling out the reporting form in the clean up kit.

   We ask that you please track the number of volunteers, hours worked and number of filled trash bags collected by filling out the reporting form in the clean up kit.

6. Clean Up Kit Questions?
   Please contact Danielle Semsrott, Senior Planner at dsemsrott@bentonvillear.com or (479) 271-6827.

   Please contact Danielle Semsrott, Senior Planner at dsemsrott@bentonvillear.com or (479) 271-6827.

8. Contact Information

10. Name

11. Neighborhood

13. Email Address

14. Phone Number

16. Clean Up Event Information

18. Requested date to pick up kit*:
    Requested date to pick up kit*:

19. Planned neighborhood clean up date:
    Planned neighborhood clean up date:

20. Date kit will be returned*:
    Date kit will be returned*:

22. *Kits may be picked up and returned to the City's Community Development Building located at 305 SW A Street, 2nd floor. Hours are M - F, 8:00 a.m. to 4:30 p.m.

24. Approximate number of adult volunteers (over 18):

25. Approximate number of youth volunteers (under 18):

27. Supplies

    Please select the supplies you will need:

    1. Trash bags
    2. Safety vets (S/M)
    3. Safety vets (L/XL)
    4. Nitrile gloves
    5. Cloth gloves
    6. Litter grabbers
    7. Bug spray
    8. Fun stickers for kids
28. Number of litter grabbers needed (if requested):

30. Location where filled trash bags will be left for city crew to pick up:

Leave This Blank:


32. 1. Receive an email copy of this form.
33. Email address

    This field is not part of the form submission.

34. Submit

* indicates a required field