📢Public Education Request Form📢
Thank you for inviting Benton County Fire District #4 to your event!
EVENT DETAILS
Requests should be submitted at least two weeks in advance.
Requested Event Date
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Hour Minutes
AM
PM
AM/PM Option
Alternate Date/Time (if available)
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Hour Minutes
AM
PM
AM/PM Option
Event / Program Name
*
Type of Request
*
Please Select
Fire & Life Safety Presentation
Fire Station Tour
Fire Engine/Apparatus Visit
School/Classroom Visit
Community Event
Smoke/CO Alarm Education
Other
Audience/Target Audience
*
Please Select
Preschool
Elementary School
Middle School
High School
Adults
Seniors
Business/Workplace
Community Group
Mixed Ages
Other
Age Range/Grade Level
*
Please Select
Pre-K
K-2
3-5
6-8
9-12
Adult
Mixed Ages
Other
Request Duration
*
Please Select
30 minutes
45 minutes
1 hour
1.5 hours
2 hours
Other
Event Location/Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Description of Request
*
CONTACT INFORMATION
Contact Person
*
First Name
Last Name
Company/Organization
Contact Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Email
*
example@example.com
Will the contact person be available at the event?
*
Yes
No
On-Site Contact Name and Phone Number
EVENT CONDITIONS / ATTENDANCE
Event Setting
Indoors
Outdoors
Both
Is this a public event?
Yes (Open to the public)
No (Invitation Only)
Attendee Count
Rows
Number of Attendees Expected
Children
Adults
Total Estimated
FIRE APPARATUS AND ACCESSIBILITY
Is Apparatus Requested? (Fire Trucks/Ambulance)
Yes
No
Apparatus Requested/Details
Is there adequate space for a fire engine or ambulance to safely enter, park, and exit?
Yes
No
List any special accommodations/additional needs
Accessibility, language, sensory, or other accommodations.
ACKNOWLEDGEMENT
Additional Pertinent Information
I understand that Benton County Fire District #4 personnel and apparatus remain available for emergency response. Scheduled public education activities may be delayed, interrupted, modified, or canceled if emergency response needs arise.
Yes, I understand.
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