Fire Prevention Education / Community Event Participation Request

Indicates Required Field

Organization Name:
Primary Contact:
Organization Address:
City :
State:
Zip:
Contact Phone Number:
Contact Email Address:
Kutztown Fire & Rescue Participation Requested: Select all that apply		Fire Safety Educational Trailer Fire Drill & Evacuation Observation Fire Extinguisher Training Fire Prevention Education Fire Station Tour Fire Truck Visit Fire Department Standby
Organization Type: Organization Type		Charity (ie. Red Cross, Salvation Army) Community Group Government Healthcare Private Education Public Education Religious Organization Residential Facility Service Orgnization (ie. Boy Scouts, Lions Club) Other
Organization Type Other: Please provide a brief description of your organization
Community Event Date & Time:
Community Event Anticipated Attendance:
Participant Age Groups: Select all that apply		Preschool Elementary School Middle School High School College Adults Seniors Families
Fire Prevention Education Scheduling : Please indicate which days and times work best. Select all that apply.		Monday Tuesday Wednesday Thursday Friday Saturday Sunday Morning Afternoon Evening
Request Details: Please provide a brief description of your request
Available Education Aids: Please indicate which equipment available at the location for use during education.		Computer Projector (with audio) Projector (no audio) Screen/Monitor White Board

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