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
     

Topics:

  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

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