Safety Seminar Request Form

Complete this form and we’ll be in touch shortly

We would love to hear from you! Please fill out this form and we will get in touch with you shortly.

Name*
Name of School or Community Site*
What are you interested in? Check all that apply*
- Helmet Safety
- Bike Safety
- Traffic Safety
- Other (describe in additional comments)
What format do you want for the Safety Seminar? Check all that apply
- School-wide Assembly
- Classroom specific
- Afterschool
- Other (describe below in additional comments)
Who requested that a Safety Seminar come to your site? Check all that apply
- You
- Parents
- Teachers
- Principals
- Students
Seminars typically last 30 minutes to include helmet and bike safety. Do you have that amount of time available with kids.
- Yes
- No
Would you also be interested in a more intensive afterschool earn a bike program? (For schools with free and reduced lunch greater than 75%)
- Yes
- No
Which grades would you like to attend the Safety Seminar? Check all that apply
- 3rd
- 4th
- 5th
- Other
Who is the best person to follow up on this request with?*
Contact email of above person*
Contact phone of above person
How did you hear about Kids on Bikes?
- Website
- School
- Friend
- Word of Mouth
- Attended other event
Additional information or comments

provides a bike toolkit

sponsors a child

sponsors a neighborhood

KIDS ON BIKES
719.355.3573
admin@kidsonbikes.net

PEDAL STATION
719.210.6427
bryan@kidsonbikes.net