Fire Safety Education Request

2. Contact Information
4. Requesting Agency*
6. Contact Name*
8. Phone Number*
10. Email Address*
14. Event Information

    (The event must be inside Greene County.)

16. Date of Event*
    Date of Event
17. Time of Event*
    Time of Event Start Time

    —

    Time of Event End Time
19. Type of Event*

    1. Preschool / Daycare Fire Safety Talk
    2. Adult Education Fire Safety Talk
    3. Pumper Truck Demonstration
    4. Elementary School Fire Safety Talk

    1. Middle School Fire Safety Talk
    2. High School Fire Safety Talk
    3. Parade
    4. Other... Please provide description.
21. Other Description
23. Address
25. City
26. State
27. Zip Code
29. I understand that the Fire Rescue Personnel that will be attending the event are on duty and may at any time need to leave for an emergency call.
31. Electronic Signature Agreement

    By checking the "I agree" box below, you agree and acknowledge that 1) your application will not be signed in the sense of a traditional paper document, 2) by signing in this alternate manner, you authorize your electronic signature to be valid and binding upon you to the same force and effect as a handwritten signature, and 3) you may still be required to provide a traditional signature at a later date.

    1. I agree.
33. Electronic Signature
Leave This Blank:


35. 1. Receive an email copy of this form.
36. Email address

    This field is not part of the form submission.

37. Submit

* indicates a required field