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2. The City of Coquitlam thanks you very much for your participation in our Adopt-A-Street Program. Please take a few minutes to complete this short five minute survey to help us better understand how the Program is working and your experiences as a participant.

4. Are you an active participant in your Adopt-A-Street location?*

   1. Yes
   2. No
5. If you selected No, please specify.
7. On average, how often do you collect in your Adopt-A-Street location?

   1. Less than once a month
   2. Once a month
   3. Every two weeks
   4. Once a week
   5. More than once a week
   6. Other
8. If you selected Other, please specify.
10. Do you currently use the online Adopt-A-Street Participation Record (coquitlam.ca/streetlog) to notify us when you’ve been out collecting and to report dumped debris, graffiti and other potential hazards?

    1. Always
    2. Usually
    3. Sometimes
    4. Rarely
    5. Never
11. Please tell us why.
13. Will you continue to volunteer until at least December 2024?

    1. Yes
    2. No
    3. Not Sure
14. If you selected ‘No’ or ‘Unsure’, please explain why.
18. Please provide us with your most recent contact information so that we may update our records.
20. First Name
21. Last Name
23. Address
24. Postal Code
26. Phone Number 1
27. Phone Number 2
29. Email Address
33. If there is an alternate person we can contact, please enter their information below.
35. Name
36. Email Address
38. Phone Number 1
39. Phone Number 2
41. Freedom of Information and Protection of Privacy Act*

    By checking "I consent" you are consenting to the voluntary collection and use of your personal information in accordance with Section 26(d) of the Freedom of Information and Protection of Privacy Act (the “Act”). The information provided by you will be used solely for the purposes of the Adopt-A-Street Program and will not be used for any other purpose. If you have any questions about the collection, storage, correction and/or use of your personal information please contact an Adopt-A-Street coordinator, 500 Mariner Way at 604-927-6205.

    1. I consent to my name being recognized in a public manner for my contribution (i.e. online or in a printed publication).
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42. 1. Receive an email copy of this form.
43. Email address

    This field is not part of the form submission.

44. Submit

* indicates a required field