Safety Speaker Request Form

Complete this form and submit online using the Continue button below.

Please allow at least two weeks notice for speaker request date.

Contact Name   Organization / School   Contact Number
    - -
Street Address    Email Address
City State    Zip
Grade   Age   Report to
Date of Program   Program Time   Num. of Teachers   Num. of Students


  Sparky & Electra (Kindergarten)
  Louie The Lightning Bug (1st - 3rd grades)
  The Shocking Truth (4th - 8th grades)
  Electric City (9th - 12th grades)

Please make the necessary resources available as described in the Safety Speaker Guidelines.
Please confirm that you can make these resources available for this presentation.

I understand

Special Instructions/Directions

Please enter the characters in the image to complete your request.