Greater Cleveland SAFE KIDS/Safe Communities Coalition
Equipment & Materials Request Form
(Must be submitted two weeks prior to the event)
Date: ________________ Your Name: ____________________________________________________________
Phone Number: (
) ________________________ E-mail address: ___________________________________
Name of Agency: _____________________________________________________________________________
Address: ____________________________________________________________________________________
Name of Event: _______________________________________________________________________________
Date of Event: ___________________Location and Time: ___________________________________________
Number of People Expected:__________ Pick-up Date : __________ Date of Expected Return:_____________
Program Related Area (circle all areas that apply):
Bike Safety
Fire Safety
Impaired Driving
Traffic
Child Passenger
Gun Safety
Pedestrian Safety
Other: ____________
Safety
High Risk Drivers
Poison Prevention
Materials Requested:
1)
2)
3)
4)
5)
6)
7)
8)
9)
10)
Items must be returned in the same condition as when picked up. You are responsible for
any lost or damaged items. Signed_______________________________________________
You must turn in a one page Activity Report form for every request.
[For office use only]
Date CSRS called/e-mailed to confirm order: ___________________
 Consultation Given
CSRC Contact: ____________________________________________
Date Returned: ____________________
Comments:
Initials: ____________
All Materials Returned:  Yes  No
Initials: _____________