Safety For ME! - Host Application

School/Organization Name*
School, Club, Company, etc.
School/Organization Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Contact Name*

First NameLast Name
Title
Contact Email*
example@example.com
Contact Phone*

Area CodePhone Number
Venue Name (If different than School/Organization)
Venue Address (If different than School/Organization)*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
What is the age range of the children? (Attention spans vary by range.)*

Ages 5-7Ages 8-11
Room Size (square feet of open space)*
How did you hear about the program?*

Company/SponsorEnewsletterFlyerFriend/FamilyPrint MediaRadioSocial MediaVoice2Change PodcastWebsiteOther
Name of Company/Sponsor*
Name of Friend/Family Member*
Estimated number of participants*
Proposed date of presentation*

MonthDayYear
Proposed time of presentation (Approx. 30-45 minutes)*

Hour Minutes

AM/PM Option

Until
until
Hour Minutes

AM/PM Option
Do you have a budget for this presentation?*

YesNo
What is your budget amount?*
Will you have a counselor available for the children during and immediately following our presentation should the need arise?*

YesNo
Will you supply A/V equipment (microphone, speakers, projector & screen)?*

YesNo
Feel free to leave any additional information or questions.
Our Safety for ME! program relies on funding from schools, individuals, businesses, organizations and foundations. We are happy to work with you to bring this program to the children in your community.
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