Education Specialist request form | Active Transportation Alliance

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Our Education Specialist can show anyone whether they are young, old, on foot, or on wheels, how to travel safely and responsibly. Please fill in as much information as possible to invite him to your community.

Event date & time info

Name of event: *

Date of event: *

Rain date:

If you have an alternate date, please enter it here.

Address:

Please enter the address where this event will be held.

City:

Zip code:

Start time:

End time:

About your event

How did you learn about us?:

Have you done this event before?:

Yes

Did you issue a press release for this event?:

Yes

What is the goal or message of your event?:

Education Specialist should focus on::

Adult bicycling safety

Helmet fitting

Commuting, shopping, and/or carrying by bike

Child bicycling safety

Motorists share the road with bikers

Bus-rack demonstration

Winter Biking

Education Specialist is requested to do::

Display

Presentation

News media interview

If you are requesting a presentation, how long will it be?: Minutes

Have people been encouraged to bring their bicycles to the event?:

Yes

Primary Contact Information

Organization Name: *

Contact name: *

Phone number: *

Contact's Address:

Contact's city:

Contact's zip code:

Contact's email address:

On-site contact for event

Check "yes" if on-site contact info is the same as the primary contact::

If so, you can leave this section blank.

Yes

Organization Name:

On-site contact name:

On-site contact phone:

On-site contact's address:

On-site contact's city:

On-site contact's zip code:

On-site contact's email address:

Audience & Venue information

Audience age groups:

1-5

6-8

9-11

12-17

18-24

25-30

31-65

66+

Number of people expected:

Site is:

Indoor

Outdoor

If outdoor:

On grass

Under tent

On pavement

On dirt

You will supply the education specialist:

A table

Chairs

Other

No equipment

If the education specialist will be assigned a booth or location number, please enter it here:

Event agenda

Will there be any of the following?:

Presentations Entertainment Items for sale Give-aways

If so, please describe::

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