SAFE KIDS KANSAS CYCLE SMART
FY2009 GRANT PROGRAM APPLICATION
Through this application your local community group, school, law enforcement, Safe Kids chapter, coalition, or other eligible organization may receive up to 50 Bell Sports bicycle helmets to support your bicycle safety program. Please allow up to 3 weeks from the date of submittal to receive your helmets. Please fill out the information below and attach a completed bike helmet order form for your 50 helmets. This grant is not retroactive for previous bicycle events. Please direct all questions to Cherie Sage at 785-296-0351, .
Complete and fax this form to 785-296-8645, email to , or mail to Safe Kids Kansas, 1000 SW Jackson, Suite 230, Topeka, KS 66612.
Name of person requesting:______
Organization:______
Address:______
City, State, Zip:______
Phone:______
Email address:______
Date of event/program: (i.e. 11/1/09, July 2009, Summer 2009)______
Description of distribution: (please give detailed description of event/program where you plan to distribute the helmets and your target audience)
______
______
Is this event/program targeting low income or minority families? YES NO
Please list all participating community partners: ______
This grant is made possible through a generous donation from
The Kansas Department of Transportation,
Bureau of Traffic Safety.