Z-2011 Safety City Participant Form

2011 Safety City Participant Form

Please complete the following form to participate in 2011 Safety City. Should you have any questions of problems, please contact Lisa Elsas at 816/701-8392 or lelsas@marc.org.

Organization	*
Name	*
Address	*
City	*
State	*
Zip Code	*
Primary Phone	*
Type	*
Secondary Phone
Type
Email
Safety City Committee Member Contact
PUBLIC SAFETY MESSAGE
Please describe the public safety message(s) you hope to convey at Safety City (e.g. general disaster preparedness, importance of wearing seat belts, helping the public better understand a public safety discipline or services, etc.)	*
Please describe what your organizations will use to convey its message at Safety City (e.g. displays, presentations, brochures, workbooks, give-aways, demonstration of equipment, etc.)	*
Are you interested in providing a 25-30 presentation? If so, please include the topic and preferred presentation times: (Note: The layout for Safety City 2011 allows for access to presentation stage. If you have suggestions for topics, please list in this section.)
SPACE REQUIREMENTS
Which of the following will you display at Safety City?
Tables and/or Display Booths:	*
Dimensions:
Vehicle and/or Trailor:	*
Dimensions:
Please indicate location/space needed for doors.
Will your display require electricity?	*
If yes, please specify electricity requirements: Example, 110 volt outlet, standard 50 amp mobile home connector, 30 amp four-wire locking type receptacle
ORGANIZATION RESPRESENTATIVES/VOLUNTEERS
How many people will represent your organization each day at Safety City? Please note: All exhibitors must provide volunteers or agency staff during the show hours.
Friday, February 11, 2011; 10 am to 9 pm
Number of Volunteers	*	FromTo
Number of Volunteers		FromTo
Number of Volunteers		FromTo
Saturday, February 12, 2011; 10 am to 9 pm
Number of Volunteers	*	FromTo
Number of Volunteers		FromTo
Number of Volunteers		FromTo
Sunday, February 13, 2011; 10 am to 6 pm
Number of Volunteers	*	FromTo
Number of Volunteers		FromTo
Number of Volunteers		FromTo
PARKING PASSES available on a first come, first served basis.
How many one-day parking passes does your agency need?	*
How many three-day parking passes does your agency need?	*