SAFE Program Agreement Form

Name Of School:(Required)

County Name:(Required)

SAFE Sponsor Name:(Required)

School/Agency Name:(Required)

Phone(Required)

Email(Required)

Address(Required)

Street Address Address Line 2 City State ZIP Code

Contact #1 Name:

Contact #1 School/Agency Name:

Contact #1 Phone:

Contact #1 Email:

Contact #2 Name:

Contact #2 School/Agency Name:

Contact #2 Phone:

Contact #2 Email:

School Color(s):(Required)

Official School Mascot:(Required)

Upload your school mascot logo (optional)

Accepted file types: pdf, jpg, png, Max. file size: 20 MB.

Participating Building Student Body Population:(Required)

Number Of Students On SAFE Team:(Required)

Do You Need Safety Vests?

Yes

Do You Need Pledge Cards?

Yes

How Many Pledge Cards Do You Have Remaining?

If an existing club adopted the SAFE program, please list their name (example: StuCo, NHS, FFA, FCCLA, KAY, FBLA, FCA):

Please indicate what grades (middle and/or high school) will be part of the SAFE program in this building: