Adopt a Patch Reporting Form

Thank you for completing your clean-up and sending the below information to us.

1. Contact Details *This question is required.

First Name

Last Name

Email Address

Mobile Phone

Organisation Name

City

State

Postcode

2. Date of the clean up *This question is required. This question requires a valid date format of MM/DD/YYYY.

calendar

3. How many people participated? *This question is required.

Adults
Children

4. How many minutes or hours did it take approximately? *This question is required. This question requires a valid number format.

5. Were there any incidents or injuries to participants? *This question is required.

Yes (Please give details) Please enter an 'other' value for this selection. * This question is required.
No

6. How many bags did you fill? *This question is required.

7. What size were the bags filled (in liters)? *This question is required. This question requires a valid number format.

8. Did you separate rubbish from recyclable litter items? *This question is required.

Yes (How many of these bags were for recyclable material only?) Please enter an 'other' value for this selection. * This question is required.
No

9. Did you pick up used syringes?

Yes (How many) Please enter an 'other' value for this selection. * This question is required.
No

10. We would like to hear if you have any other comments, unusual items found or suggestions

11. Could you upload photos from the cleaning?
By uploading photos, I give Keep Australia Beautiful permission to use these photos in online and print publishing.

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