Request Form

Please note that all fields marked with * are required. If the answer does not apply, please write in Not Applicable.

Event Information

Event*

Date of Event (mm/dd/yy)*

Rain Date (mm/dd/yy)

Address where event will take place

Ward: Police District #:

Start Time*:    End Time*:  

How did you learn about us? 

Have you done this event before?
 Yes   No

Did you issue a press release for this event? 
 Yes   No

Goals for your Event

Goals/message at the event*: 

Ambassadors should focus on:
adult bicycling safety
helmet fitting
commuting, shopping and/or carryingby bike
child bicycling safety
motorists share the road with bikers
bus-rack demonstration

Ambassadors are requested to do:
display 
presentation (length: minutes)  
news media interview

About Your Guests

Have people been encouraged to bring their bicycles to the event?
 Yes 
 No

What non-English languages will people speak at this event?
Spanish
Polish
Korean
Chinese   
Other  

Primary Contact Information

Organization:

Name*:

Phone*:

Fax:

Address:

Zip:

E-mail:

On-Site Contact for Event

Organization:

Name*:

Phone*:

Fax:

Address:

Zip:

E-mail:

Your Audience

Ages:
1-5
6-8
9-11
12-17
18-24
25-30
31-65
66+

No. of people expected:

If this is a children's event, how will they arrive?

Others attending:

Site Information

Indoor 
Outdoor 

If outdoor:
on grass 
under tent 
on pavement 
on dirt

Supplies

You will supply the Ambassadors:
a table 
chairs 
other  
no equipment

If the Ambassadors are assigned a booth or location number, enter here 

Event Agenda

Will there be:

Presentations?
No   Yes  If yes, describe:

Entertainment?
No   Yes   If yes, describe:

Items for sale?
No   Yes   If yes, describe:

Give aways?
No   Yes   If yes, describe: