BEACH INFORMATION Beach Name: Beach Location:   YOUR CONTACT INFORMATION: Your Name: Email address: * Title: Organization Name: Street Address: Town / City: State / Prov : Postal / Zip Code: Country : Work phone number: BEACH MANAGEMENT CONTACT INFORMATION (IF DIFFERENT FROM ABOVE): Name: Title: Email address:     NHBC PLEDGE: As part of the National Healthy Beaches Campaign (NHBC), I/We hereby acknowledge the importance of maintaining the health and safety of this special environment. I/We understand and hereby agree to cooperate with NHBC in its monthly monitoring efforts of the aforementioned beach(es) and further agree to notify NHBC immediately of anysubstandard, unsafe or unhealthy conditions. I/We acknowledge and agree to the foregoing statement. * Yes