Safe Kids Greater Houston
Membership Application
Yes! I would like to be a part of the Safe Kids Greater Houston coalition and pledge to fight unintentional childhood
injury by participating in the coalition through community action, educational interventions, public policy initiatives, and
media efforts.
NAME_________________________________________TITLE______________________________________________
ORGANIZATION___________________________________________________________________________________
ADDRESS_________________________________________________________________________________________
EMAIL_______________________________ PHONE (___)________________ FAX (___)______________________
May we list your organization as a Safe Kids Greater Houston coalition member in literature?
Yes
No
I am interested in supporting the coalition in the following areas (check all that apply):
Providing volunteers to help conduct coalition events.
Supporting coalition activities with donations of funding or in-kind goods and services.
Hosting or sponsoring a Safe Kids Greater Houston coalition event or program.
Printing or photocopying coalition materials.
Including Safe Kids Greater Houston coalition information in your publications.
Providing my materials for distribution through the coalition’s activities.
Serving on a general speaker’s bureau
Serving on a speaker’s bureau focusing only on a particular risk area
Mailing information to our members, staff, and supporters.
Documenting and distributing monthly meeting minutes.
Participating in a risk area group for the coalition (see below).
Organizing letter writing or phone calling campaigns to state and federal lawmakers in order to support a certain
public policy effort.
____________________________________________________________________________________________________
Risk Area Subcommittees:
Bicycle safety
Child Passenger safety
Pedestrian safety
Home Safety (includes fire
and poison safety)
Water safety
I understand that acceptance of this application by the coalition does not constitute permission to use the local or state Safe
Kids coalition logo, name or materials without first receiving approval from the Safe Kids Greater Houston’s lead
agency, Texas Children's Center for Childhood Injury Prevention. The lead organization for the coalition will not authorize,
and will not permit any member of the coalition to authorize, any person or organization to use the name and trademarks to
promote its products or services for endorsement or other commercial purpose.
SIGNATURE
DATE: ____________
Safe Kids Greater Houston ◊ PO Box 300630 ◊ Houston, TX 77230 ◊ 832-824-3482