	Safety Street reservation or information request form

Please fill out as much of this form as you feel comfortable. Remember that that more information you provide us, the better able we will be to assist you. When you are finished, please click the "Submit" button to send your information to the Kansas City, Mo., Health Department.

Your name:
Your phone number:
Your e-mail address:
The name of the organization sponsoring the children:
Type of organization
Church School After school Neighborhood Day care Other
Organization phone number:
Date(s) you are considering:
Number of children you may bring:
Approximate age range of children:
Comment or question:
Thank you for taking the time to fill out this form and express an interest in Safety Street. If you have any further questions or comments, or do not hear back from us within a reasonable time, please contact us at 816-513-6079 or 816-513-6324.