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									                                                                       Date of request_______________

                     Rain Barrel Donation Request Form
           (If you need more room please submit supplementary sheets, do not leave out information)

Buffalo Niagara RIVERKEEPER’s priority sites are: high visibility sites such as key public
buildings, government offices, community gardens, schools and education centers in low income
communities within the Buffalo and Niagara River watershed. Organizations that service
multiple sites are invited to apply for those multiple sites.

To be eligible, you must have an external gutter system with a downspout to divert into the
rain barrel!

Name: ______________________________ Title: ____________
Organization: ______________________________________
Address: __________________________ City_______________,
State_____ Zip_______
Phone: (_____) ______- ___________
Email: ________________________________________
Fax: (_____) ______- ___________
Address or location of Barrel (if different from above):
Street _________________________
City ___________________, State ________________
What is the mission of the organization? Please explain how you serve the community. Please
describe the community that you serve.

What purpose will the rain barrel serve at your facility?
How many people will be educated about the rain barrel at your site annually? ________
How many people visit your site annually? _______________
Describe the visibility of rain barrel. (For example, is it within street view or hidden in the
back of the building. Will it be a focal point in your garden?)

Who owns the building where the barrel will be installed?

Is the location a nonprofit, school or university, public building?

How many barrels would you like to request? (Up to two barrels per site) ______

Do you have an external gutter with a downspout? (Circle One)            Yes         No

Would you like a Downspout Diverter? (Circle One)             Yes           No
(If you do not have a downspout, you may not be able to collect the rainwater)

What size Diverter would you need? (Circle One)                       2”x3”      3”x4”

Size roof area will be draining into rain barrel (square feet)? ____________

Do you have someone to install and maintain the barrel? (Circle One) Yes No
Name _____________________________________
Title ______________________________________
Experience _________________________________
How do you plan to use the water? __________________________________

If for a garden:
Is it a rain garden? (Circle One)

Yes          No                No, But I would like more information on Rain Gardens

Are you using native plants? (Circle One)

Yes          No                No, But I would like more information on Native Plants

Who will be responsible for tending to the garden and using the barrel?
Name _____________________________________
Title ______________________________________
Experience _________________________________
Do you need your Rain Barrel(s) delivered? (Circle One)          Yes      No

What color to you prefer? (Circle One)            Green       Gray           Brown
(Buffalo Niagara RIVERKEEPER cannot guarantee color availability.)

Workshops are in the process of being scheduled. If you are interested in hosting one or
attending please contact Adrienne Kina,, 852-7483 ex. 19

Diverters, that make seasonal changes easier, are also available
upon request.

Next steps:       Once approved, an appointment will be made with you to set up a site visit and
to deliver the barrel, if needed.

If approved, before you receive your Rain Barrel, you must agree to
  and sign the maintenance agreement, no exceptions will be made.
Please submit your requests online at or return this application form to:

       Buffalo Niagara RIVERKEEPER
       Rain Barrel Donation Program
       1250 Niagara St
       Buffalo, NY 14213.

For questions or more information, please contact Kerri Bentkowski at (716) 852-RIVER or

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