FIRE SAFETY
EDUCATION PROGRAMS
Program Request Form
Today’s Date: ___________ Program Date / Time: ______________ Shift: _____
Organization / Group: ___________________________________________________________
Program Site / Address: __________________________________________________________
Estimated Audience: (Size) __________________ (Age Group) _______________
Requested By: ________________ Phone (Contact) ____________ (Fax) ________________
Mailing Address: _______________________________________________________________
Comments: ____________________________________________________________________
Program Type:
Supplies Needed:
Commercial Fire Safety Program ________________________________
Fire Station Tour ________________________________
Learn Not to Burn ________________________________
School Program ________________________________
Fire Safety House ________________________________
Juvenile Fire Setters ________________________________
Special Event ________________________________
Program by Staff (Describe) ________________________________
Staffing / Apparatus Requested: ___________________________________________________
Complete the lower section after the program and return to the Technical Services Division
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Size of Audience (Circle Grade):
Fire Personnel Used:
# Preschool ______________ On Duty Personnel: _______________
# Primary (K, 1, 2) ______________ Off Duty/Overtime: _______________
# Elementary (3, 4) ______________ Volunteers: ______________________
# Intermediate (5, 6) ______________ COMMENTS:
# Jr. High (7, 8) ______________ ________________________________
# Sr. High (9, 10, 11, 12) ______________ ________________________________
# of Adults (Age 18-64) ______________ ________________________________
# of Seniors (Age 65 +) ______________ ________________________________
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