Bloomfield Streets & Sidewalks Improvement Survey

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Thank you for completing this survey in order to urge the City of Rogers to consider updating the crumbling streets and walkways in the Bloomfield neighborhood. All details provided will remain anonymous.

First & Last Names (optional)

Residence Address (optional)

How concerned are you with the the state of the streets and walkways in the Bloomfield Neighborhood? *

Not concerned

Very concerned

Do you have any young children in your household (12 and under?) *

Yes

If you answered yes, how many children ages 12 and under live in your household?

Do you have any household members with disabilities or special needs that give you additional reasons to be concerned with the safety or our streets and sidewalks? *

Yes

If you answered yes, how many household members with disabilities or special needs that give you additional reasons to be concerned with the safety or our streets and sidewalks?

Do you have any additional feedback about our streets and sidewalks that you'd like the City of Rogers to made aware of?

Would you like to be included in email updates from the Bloomfield Homeowners Association (membership is not required to receive updates.)

Please provide the best email address(es) to include in email updates:

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This form was created inside of Cypress & Pine.