Roster Request & Permission Form
PLEASE PRINT CLEARLY!
First Name
________________________________________________
Last Name
________________________________________________
Title
________________________________________________
Agency
________________________________________________
Address
________________________________________________
City
________________________________________________
State
________________________________________________
Zip
________________________________________________
Phone
________________________________________________
Fax
________________________________________________
E-mail ________________________________________________
Please send me Coalition meeting notices, updated Coalition roster and important coalition
announcements.
Yes
No
I give permission for the Safe Kids Greater Sacramento roster containing my contact
information to be shared with members of the Safe Kids Greater Sacramento coalition only.
Yes
___________________________________________
Signature
No
__________________
Date
If you have questions or concerns, please feel free to contact:
Jennifer Rubin, Coalition Coordinator
Phone: 916-864-5684, Fax 916-864-5693, or [email protected]