Injury Prevention and EMS

Kids Don't Float Program Request Form

Contact Person:

Sponsor Name:

Address (Include a Shipping Address for PFD's)

Work Phone:

Fax Number:

Email:

Comments:

 

Site Information

(Enter up to four sites.  Submit this form again to add more sites.)
Site Description (Local Name) Site: (City/Town/Village) Site: New or Renewal (Check only one) 

Site 1:


New         
 Renewal

Site 2:


New          
Renewal

Site 3:


New          
Renewal

Site 4:


New          
Renewal

 

Number of PDF Sets:

(One set includes 2 infant, 4 child, 4 youth, 3 adult and 1 X-Large adult PFDs)

 

-OR-

 

Order by size:

Number of KDF Signs:

The sign is a 2 x 4 foot adhesive decal

Would you be interested in learning about the youth Peer Education program?

 Yes           No thank you
Would you be interested in classroom activities for teaching boating safety?

 Yes           No thank you
 
Additional Comments:

THANKS for promoting Kids Don't Float and making it a viable program in your community. Kids Don't Float is a statewide effort to reduce unintentional injury and drowning supported by the Alaska Department of Health and Social Services, the 17th Coast Guard District, the Alaska Boating Safety Program, and Alaska Safe Kids.

Click the "Send" button to submit information to the Kids Don't Float Office!