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

Presentations are available for the following 2 age ranges as attention spans vary by range. Please select both if applicable.

Estimated number of 5- to 7-year-olds.

Estimated number of 8- to 11-year-olds.

Room Size (square feet of open space)

How did you hear about the program?

Name of Company/Sponsor

Name of Friend/Family Member

Name of School & Staff Member

Proposed date of presentation

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?

What is your budget amount?

Will you have a counselor available for the children during and immediately following our presentation should the need arise?

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

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.