DOT Form 1210A "Adopt a Highway Application" - Kansas

DOT Form 1210A is a Kansas Department of Transportation form also known as the "Adopt A Highway Application". The latest edition of the form was released in April 1, 2014 and is available for digital filing.

Download a PDF version of the DOT Form 1210A down below or find it on Kansas Department of Transportation Forms website.

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Download DOT Form 1210A "Adopt a Highway Application" - Kansas

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APPLICATION
ADOPT A HIGHWAY
KANSAS DEPARTMENT OF TRANSPORTATION
The Kansas Department of Transportation's Adopt-A-Highway program is voluntary, designed for civic-minded groups or
businesses with an interest in keeping our highways litter-free. It is open to families, youth organizations, civic groups,
non-profit organizations, churches, schools, social organizations, neighborhood groups, service organizations, retiree
organizations, and city, county or state agencies. Eligible groups must comply with state laws prohibiting discrimination
based on race, religion, color, age, gender or national origin. Each volunteer (adopting) group assumes responsibility for
an assigned section of highway and agrees to remove litter and trash a minimum of three times a year for a two year period.
DATE: ______________________
PLEASE PRINT ALL INFORMATION BELOW
NAME OF GROUP
NAME TO APPEAR ON ROAD SIGN (30 letters/spaces maximum)
GROUP’S MAILING ADDRESS
CITY
ZIP CODE
GROUP’S AUTHORIZED REPRESENTATIVE (President, other Officer or Representative)
GROUP’S ADOPT-A-HIGHWAY CONTACT
CONTACT'S TELEPHONE NUMBER
(NIGHT)
(DAY)
CONTACT'S EMAIL
APPROXIMATE NUMBER OF PARTICIPATING MEMBERS IN GROUP: _______________________________
(KDOT recommends applying groups have a minimum of five members able to participate in litter Pickups to be able to
effectively control litter on the assigned highway section.)
(
): ______________
ESTIMATED NUMBER OF PEOPLE PARTICIPATING IN EACH CLEANUP
minimum of 3
(F
or safety reasons, a minimum of three members must be involved in litter Pickup events.)
HIGHWAY SECTION(S) YOU ARE INTERESTED IN ADOPTING (in order of preference): The Kansas Department
of Transportation will work with the adopting group to select the specific section of highway to be adopted. KDOT may not
allow some highway sections to be adopted for safety or other considerations. Groups may be placed on a waiting list if they
are interested in a particular section that is already adopted.
HIGHWAY
LOCATION – DESCRIPTION
R.P. TO R.P.
1.
_________________________
_______________________________________________
_____ TO _____
2.
_________________________
____________________ ___________________________
_____ TO _____
3.
_________________________
_______________________________________________
_____ TO _____
KANSAS DEPARTMENT OF TRANSPORTATION
MAIL FORM TO:
ADOPT-A-HIGHWAY PROGRAM
____________________________________________________________
________________________________________________________________________
DOT FORM NO. 1210A
Rev. 4-2014
APPLICATION
ADOPT A HIGHWAY
KANSAS DEPARTMENT OF TRANSPORTATION
The Kansas Department of Transportation's Adopt-A-Highway program is voluntary, designed for civic-minded groups or
businesses with an interest in keeping our highways litter-free. It is open to families, youth organizations, civic groups,
non-profit organizations, churches, schools, social organizations, neighborhood groups, service organizations, retiree
organizations, and city, county or state agencies. Eligible groups must comply with state laws prohibiting discrimination
based on race, religion, color, age, gender or national origin. Each volunteer (adopting) group assumes responsibility for
an assigned section of highway and agrees to remove litter and trash a minimum of three times a year for a two year period.
DATE: ______________________
PLEASE PRINT ALL INFORMATION BELOW
NAME OF GROUP
NAME TO APPEAR ON ROAD SIGN (30 letters/spaces maximum)
GROUP’S MAILING ADDRESS
CITY
ZIP CODE
GROUP’S AUTHORIZED REPRESENTATIVE (President, other Officer or Representative)
GROUP’S ADOPT-A-HIGHWAY CONTACT
CONTACT'S TELEPHONE NUMBER
(NIGHT)
(DAY)
CONTACT'S EMAIL
APPROXIMATE NUMBER OF PARTICIPATING MEMBERS IN GROUP: _______________________________
(KDOT recommends applying groups have a minimum of five members able to participate in litter Pickups to be able to
effectively control litter on the assigned highway section.)
(
): ______________
ESTIMATED NUMBER OF PEOPLE PARTICIPATING IN EACH CLEANUP
minimum of 3
(F
or safety reasons, a minimum of three members must be involved in litter Pickup events.)
HIGHWAY SECTION(S) YOU ARE INTERESTED IN ADOPTING (in order of preference): The Kansas Department
of Transportation will work with the adopting group to select the specific section of highway to be adopted. KDOT may not
allow some highway sections to be adopted for safety or other considerations. Groups may be placed on a waiting list if they
are interested in a particular section that is already adopted.
HIGHWAY
LOCATION – DESCRIPTION
R.P. TO R.P.
1.
_________________________
_______________________________________________
_____ TO _____
2.
_________________________
____________________ ___________________________
_____ TO _____
3.
_________________________
_______________________________________________
_____ TO _____
KANSAS DEPARTMENT OF TRANSPORTATION
MAIL FORM TO:
ADOPT-A-HIGHWAY PROGRAM
____________________________________________________________
________________________________________________________________________
DOT FORM NO. 1210A
Rev. 4-2014
2
APPLICATION
ADOPT A HIGHWAY
KANSAS DEPARTMENT OF TRANSPORTATION
FOR OFFICE USE ONLY
RECEIVED BY KDOT: DATE _____________________________________ TIME: __________
RECOMMENDED BY KDOT AREA ENGINEER: __________________________________________________________
KDOT DISTRICT ADOPT-A-HIGHWAY COORDINATOR APPROVAL: ______________________________________
______________________________________________________________________ DATE: _______________________
NOTE: This information is available in alternative accessible formats. To obtain an alternative format, contact the KDOT Office of Public Affairs,
Dwight D. Eisenhower State Office Building, 700 SW Harrison ST., TOPEKA, KS 66603-3754 or phone (785) 296-3585 (Voice)/(TTY).
DOT FORM NO. 1210A
Rev. 4-2014
AGREEMENT OF TERMS AND CONDITIONS
ADOPT-A-HIGHWAY
KANSAS DEPARTMENT OF TRANSPORTATION
Eligible Groups:
Civic minded groups or businesses with an interest in keeping our highways litter-free, including
families, youth organizations, civic groups, non-profit organizations, churches, schools, social organizations, neighborhood
groups, service organizations, retiree organizations, and city, county or state agencies. Eligible groups must comply with
state laws prohibiting discrimination based on race, religion, color, age, gender or national origin.
Non-Eligible Groups:
Any group whose name promotes or opposes an elected official or candidate for public office is
not eligible to participate in the Adopt-A-Highway Program. In addition, adoptions are not allowed for political candidates
and/or their election campaign organizations, elected officials, or entities that may constitute partisan endorsements.
Additional Restrictions and Conditions:
Each volunteer (adopting) group assumes responsibility for
an assigned section of highway and agrees to remove litter and trash a minimum of three times a year for a two year period.
The program is not intended as an advertising medium or a means of providing a public forum for groups, individuals or
businesses to use in promoting name recognition, a particular cause, or a political candidate or position. Participants may not
display messages, carry banners, or advertise their business or group affiliation or cause. The safety of those collecting litter
and the traveling public are of paramount concern. For that reason, while collecting litter on right-of-way, the method,
manner and appearance of the participants should be conducted in a way as to not distract, disrupt, or adversely affect traffic
or the safety of the traveling public.
Risks:
Picking up litter on highway right-of-way involves risks and hazards posed by traffic, nature, the
condition of the right-of-way and hazardous materials which may be found on the right-of-way.
The Kansas Department of Transportation, (KDOT), and
(Group)
___________________________________________________________________________________________,
NAME OF GROUP
are entering into this agreement to permit the Group to contribute towards the effort of
maintaining litter-free highways by performing litter pick ups (Pickups).
CONDITIONS AGREED TO BY GROUP:
By signing this agreement, the Group agrees to comply, and require those participating in Pickups to comply, with the
following conditions and any other conditions imposed or directions provided by KDOT.
1.
A Group shall not allow any person to participate in a litter Pickup without having first obtained a signed release
form or consent form for that person. It is the option of the Group to have the release forms and consent forms signed
prior to each Pickup or one signed release form and consent form per participant for the term of the agreement. The Group
shall be responsible to obtain release forms and consent forms for participating members that join anytime during the term of
the agreement. The release forms and consent forms for each participant are made a part of this agreement.
2.
The Group shall obtain a consent form (DOT Form No. 1210D) for each participant between the ages of 11 and 18. The
consent from shall be signed by either a parent or guardian, and the child.
3.
The Group shall conduct a safety meeting prior to each roadside Pickup. All participants must attend and agree in
writing to assume the risks involved in the work by signing the release forms and consent forms (if applicable). All
participants agree to comply with all safety measures imposed by KDOT as described in the safety meeting, Adopt-A-
Highway Safety Brochure and/or Adopt-A-Highway Safety Video.
4.
The Group shall notify the KDOT office at (_______________________________________), at least two days prior to
its planned Pickup time.
5.
The minimum length of highway to be adopted in rural or undeveloped areas is two miles; this minimum length may be
reduced to one mile for Pickups permitted in urban areas.
Rev. 4-2014
DOT FORM NO. 1210B
AGREEMENT
2
The Group agrees to adopt its section of highway for a minimum of two-years. The Group may submit a renewal
6.
application if it wishes to continue with the program after the expiration of its two year commitment.
Participants must be at least 11 years of age; younger persons shall not be permitted to accompany the Group. There must be
7.
one adult supervisor on-site for every five participants between the ages of 11 and 18.
The Group shall pick up litter a minimum of three times a year (recommended schedule early spring, summer and early
8.
fall). No Pickup may be scheduled on state-recognized holidays or holiday weekends.
9.
The following safety measures shall be followed by all persons engaged in Pickups on the right-of-way:
An appropriate safety vest furnished by KDOT must be worn.
a.
Pickup efforts must be conducted by a group of at least three people; no individuals may pick up trash alone or
b.
with only one other person present.
c.
All Pickup activities must be accomplished during the daytime hours, which is the period commencing one
hour after sunrise and ending one hour before sunset.
d.
Pickup is conducted on only one side of the roadway at a time. If both sides of the highway are assigned, Pickup
must be completed on one side of the road before Pickup is begun on the other side.
e.
Pickup activities shall not be conducted during incliment weather.
f.
Pickup shall not start until the adopting Group displays the fold-down traffic control warning signs installed on
Adopt-A-Highway sign supports at each end of their adopted section of highway. The sign shall be returned to its
folded-up position after the cleanup has been concluded.
g.
Use of controlled substances (including alcoholic beverages) is prohibited.
10.
The Group shall obtain KDOT furnished materials (trash bags, safety vest, safety DVD, safety brochure and forms)
during regular KDOT working hours.
Signed release forms and consent forms, unused trash bags and unused safety brochures shall be returned to the KDOT
11.
office during KDOT working hours within one week following Pickup.
The Group will place filled trash bags to be removed and disposed of by KDOT at locations designated by the KDOT
12.
office, along the outside shoulder edge.
The Group shall not interfere with, stop or direct traffic.
13.
Participants shall not display messages, carry banners, or advertise their business or group affiliation or cause during
14.
Pickups. While collecting litter on right-of-way, the method, manner and appearance of the participants should be conducted
in a way that does not distract, disrupt or adversely affect traffic or the safety of the traveling public. Clothing worn by
participants shall be consistent with this provision.
The Group shall not undertake any activities other than picking up litter on the right-of-way. This includes mowing or
15.
other maintenance activities.
The Group shall not trespass on non-KDOT property or interfere with the rights of private landowners.
16.
The Group shall observe traffic control when traveling by vehicle in the assigned area and observe areas where vehicles
17.
should not be parked.
The Group shall notify KDOT of any publicity efforts for the Pickup before each Pickup.
18.
Children under the age of 11, pets or persons who have not signed a release forms and consent forms shall NOT be
19.
allowed at the Pickup area or in the vehicles parked by those picking up trash.
Rev. 4-2014
DOT FORM NO. 1210B
3
AGREEMENT
The Group shall notify the KDOT office within 24 hours of the occurrence of any injury to any person or accident with
20.
occurs during Pickup.
21.
The Group understands and agrees that while applying groups may request a specific section on highway for adoption,
they are not guaranteed to receive their preference and have no right to adopt a specific section. KDOT will work with the
applying group to select a section of highway to be adopted. KDOT may not allow some highway sections to be adopted for
safety or other considerations. Should a Group's adoption of a highway section be the cause of public demonstrations, protest
or disturbances that would pose a threat to public safety or to the safety of the Group's members, KDOT reserves the right to
assign a different section of highway to the Group.
The Group understands and agrees that the sole purpose of the sign to be provided and erected by KDOT on its adopted
22.
highway section is to identify the adopting Group, and is not intended to advertise the Group's services, products, or
locations, or to provide a public forum to promote a cause, belief, message or position. Political or business slogans, logos,
taglines, phone numbers and website addresses are not allowed.
Failure to comply with any of the terms and conditions of this agreement, including the Group's responsibilities for the
23.
required number of Pickups may result in revocation of this agreement by KDOT and/or KDOT's refusal to renew the
Group's participation in the program.
KDOT AGREES TO:
1.
Provide and erect a sign at each end of the adopted highway section identifying the adopting Group. The identification
on the sign is limited to the Group's name or acronym of up to 30 characters (letters/spaces). Political or business slogans,
logos, taglines, phone numbers and websites addresses are not allowed. Profanity and/or sexual innuendo will not be allowed
as a name or acronym to be displayed on the identification sign. KDOT has full discretion to determine whether a name or
acronym contains profanity or sexual innuendo, or is otherwise ineligible for use on a sign. KDOT will work with sponsors
in revising Group names or acronyms that may be considered ineligible.
2.
Replace a Group's idenfication signs once due to vandalism or theft at no cost to the Group. If a sign needs replacing
more than once, KDOT may give the Group the option to pay for an additional replacement sign. Vandalized signs which are
not eligible for replacement (or the Group has elected no to pay for a replacement) may be removed by KDOT at its
discretion. The absence of a Group's sign does not relieve the Group of its responsibility to continue Pickups for the
remainder of its two-year adoption commitment. KDOT will not replace a sign during the adoption term only to reflect a
change in the name of the Group.
Provide safety vests, trash bags and instructional safety literature.
3.
Removed the filled trash bags after the Pickup.
4.
Provide press information upon request from the media.
5.
6.
Assist the Group in planning an initial information and safety meeting.
NOTE: KDOT will not routinely pick up litter from the adopted section. KDOT will pick up large, heavy, or hazardous
materials when found.
NOTE: This information is available in alternative accessible formats. To obtain an alternative format, contact the KDOT Office of Public Affairs,
Dwight D. Eisenhower State Office Building, 700 SW Harrison ST., TOPEKA, KS 66603-3754 or phone (785) 296-3585 (Voice)/(TTY).
Rev. 4-2014
DOT FORM NO. 1210B
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