"BE A HERO" Keep Kids Safe from Lead Resource Fair Registration

Share your contact details, household info, and event preferences so we can plan screening and follow-up. Everyone who preregisters receives an extra raffle entry.
Full Name

First NameLast Name
Email Address
example@example.com
Mobile Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Home Address

Street Address

Street Address Line 2
CityState / ProvincePostal / Zip Code
Household Demographics (Select all that apply)
Housing Status
Estimated Year Home Was Built
How did you hear about this event?
I give permission for department staff to contact me about lead service line replacement, lab results, or grant opportunities.
Should be Empty: