2023 Boater and Water Safety Classroom Program Order Form

The Dominic Trionfo Memorial Fund * P.O. Box 1023, Middle Island, NY 11953

www.dominicmemorialfund.org

Please submit by 03/15/23. Kits will be shipped by early May 2023.

A digital link is available on our web site to share for classroom use.

Thank you for your support of our program.

Name and Position of Person Ordering

Name and Position of Contact Person

School District

Contact Email Address

Contact Phone Number

Contact Address

Delivery Address

(Please include a person’s name and school with the delivery address. If more than one address, please email the additional information and quantity or indicate each address on a separate sheet.)

Total Number of Classroom Kits (Please order one kit of 30 for each class.)*

(Each kit includes 30 activity books, 30 parent letters, and a teacher guide.) Please give breakdown if available below.

Grade? How many classes per grade? About how many students per class?

Please press submit after filling out this form. Any additional notes can be added below. Please contact us at info@dominicmemorialfund.org with any questions or with additional information. Thank you for being a part of our Boater and Water Safety Program!