Safe Kids Greater Toledo Membership Form

Safe Kids Greater Toledo Membership Form

2025
Last Name*
First Name*
Organization*
Title
Email*
Cell Phone Number
Please enter a valid phone number.
Work Phone Number
Please enter a valid phone number.
Work Address*

Street Address

CityState

Zip
Home Address

Street Address

CityState

Zip
Birth Date*

MonthDayYear
Date
My agency runs a background check:*

Yes and I am willing to provide to SKGTNo, below is last 4 of social security #
Participation by our members is critical to the success of the organization. We encourage all members or organization representatives to participate in events and meetings.
Please mark the initiatives that you would like to participate in: (you may select more than one)*

Fire SafetyOccupant Protection/ Child Passenger SafetyChild Passenger Safety TechnicianChild Passenger Safety InstructorSports, Bike & Pedestrian SafetyHome and Water Safety
The mission of Safe Kids Greater Toledo is to protect Toledo area children (birth to age 18) from unintentional injury through a multifaceted community response of enactment/enforcement, engineering, education & evaluation.

AS A COALITION MEMBER FOR SAFE KIDS GREATER TOLEDO, I UNDERSTAND AND AGREE THAT:

1. Any Safe Kids Greater Toledo Coalition member, at any time, may be subject to a criminal background check unless a copy is provided.

2. I will actively support the mission and values of Safe Kids Greater Toledo, by attending at least one meeting or event within the two-year duration of this membership form.

3. I will wear my Safe Kids Greater Toledo identification badge and whenever possible Safe Kids Greater Toledo apparel when representing Safe Kids Greater Toledo at events.

4. Safe Kids Greater Toledo reserves the right to end my coalition member status because of failure to comply with this agreement and any Safe Kids Greater Toledo policies and procedures, or any other circumstances which, in the sole judgment of the Safe Kids Greater Toledo Coalition Executive Committee would make my continued service as a coalition member contrary to the best interests of the community or Safe Kids Greater Toledo.
5. Photography/Videotaping/Imaging Consent: I hereby give my consent for photographing, videotaping, filming, or other recording without compensation, to be used for the following purposes: (please check all that apply)*

Organizational Marketing or Publicity purposesInterviews with News MediaEducation purposesSocial Media
I have read and understand each of the above conditions. By typing my full name below, I acknowledge and I agree to the terms above.*

I understand that typing my name below serves as my acknowledgment of the terms above.
Full Name *
Signature*

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Submission Date*
Submission Date

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