Home About the Program For Pack Leaders For Dealers For Safe Kids Coalitions & Chapters

Chapter and Event Information

*1.

Chapter Name: Safe Kids _________

*2.

State Coalition ID:

*3.

Chapter Coordinator

Email Address:

(Maximum response 255 chars, approx. 5 rows of text)

Phone Number:

*6.

Event Date:

Month

Day

Year

*7.

Start Time:

*8.

End Time:

Event Description:

Chevrolet Dealership Information

*10.

Dealership Name:

*11.

Street:

(Maximum response 255 chars, approx. 5 rows of text)

*12.

City:

*13.

State Code:

*14.

ZIP Code:

*15.

Number of Scouts Confirmed

*16.

List the Pack Numbers for each participating Pack

*17.

Dealer Contact

Shipping Information for event Materials

*18.

Shipping Address

19.

Shipping Address 2

*20.

City

*21.

State

*22.

Zip

*23.

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