BURN PREVENTION FOUNDATION AND BERKS COUNTY KIDS SAFETY HOUSE TASK FORCE REQUEST FOR USE FORM Date "Request For Use Form" Submitted Name of Organization Address City, State, Zip Code Contact Person Home Phone Number (required) Work Phone Number (required) Email Address (required) Day(s) of Week of Presentation Sun M T W Th F Sat Date(s) of Presentation January February March April May June July August September October November December Date & Time of Trailer Pick-up a.m. p.m. Date & Time of Trailer Return a.m. p.m. Describe type of program or event & estimated number of children: Location of Program or Event: Name of Company Officer to Sign "Use Agreement": List of names of Burn Prevention Foundation Trained Instructors to conduct program: NOTICE!! All instructors and assistants are required to comply with all sections of the BERKS COUNTY KIDS SAFETY HOUSE OPERATIONS MANUAL and the SAFETY HOUSE AGREEMENT. Telephone 610.208.2279 and notify the Communication Center if your organization will be cancelling or can not meet the time table for pick-up or return of the Kids Safety House. THIS "REQUEST FOR USE FORM" WILL BE REVIEWED AND THE CONTACT PERSON NOTIFIED IF YOUR REQUEST HAS BEEN GRANTED. A "KID'S SAFETY HOUSE USE AGREEMENT" WILL THEN BE SENT TO YOU AND MUST BE COMPLETED, INCLUDING A "CERTIFICATE OF INSURANCE" FROM YOUR ORGANIZATIONS AGENT, 5 DAYS BEFORE SAFETY HOUSE USE.

A primary grades children's education program of the Burn Prevention Foundation.
236 N. 17th Street, Floor 2, Allentown, PA 18104
tele: 610.969.3930 / fax: 610.969-3940

The Berks County Kid's Safety House Task Force
welcomes your comments and questions!