subject_line
AFRD Community Affairs Education Program Request
First Name
*
Last Name
*
Email Address
*
🛈
Phone Number
*
🛈
City
*
ZIP Code
*
State
County
*
Appling
Atkinson
Bacon
Baker
Baldwin
Banks
Barrow
Bartow
Ben Hill
Berrien
Bibb
Bleckley
Brantley
Brooks
Bryan
Bulloch
Burke
Butts
Calhoun
Camden
Candler
Carroll
Catoosa
Charlton
Chatham
Chattahoochee
Chattooga
Cherokee
Clarke
Clay
Clayton
Clinch
Cobb
Coffee
Colquitt
Columbia
Cook
Coweta
Crawford
Crisp
Dade
Dawson
Dekalb
Decatur
Dodge
Dooly
Dougherty
Douglas
Early
Echols
Effingham
Elbert
Emanuel
Evans
Fannin
Fayette
Floyd
Forsyth
Franklin
Fulton
Gilmer
Glascock
Glynn
Gordon
Grady
Greene
Gwinnett
Habersham
Hall
Hancock
Haralson
Harris
Hart
Heard
Henry
Houston
Irwin
Jackson
Jasper
Jeff Davis
Jefferson
Jenkins
Johnson
Jones
Lamar
Lanier
Laurens
Lee
Liberty
Lincoln
Long
Lowndes
Lumpkin
Macon
Madison
Marion
McDuffie
McIntosh
Meriwether
Miller
Mitchell
Monroe
Montgomery
Morgan
Murray
Muscogee
Newton
Oconee
Oglethorpe
Paulding
Peach
Pickens
Pierce
Pike
Polk
Pulaski
Putnam
Quitman
Rabun
Randolph
Richmond
Rockdale
Schley
Screven
Seminole
Spalding
Stephens
Stewart
Sumter
Talbot
Taliaferro
Tattnall
Taylor
Telfair
Terrell
Thomas
Tift
Toombs
Towns
Treutlen
Troup
Turner
Twiggs
Union
Upson
Walker
Walton
Ware
Warren
Washington
Wayne
Webster
Wheeler
White
Whitfield
Wilcox
Wilkes
Wilkinson
Worth
Organization/Contact Persons Name
*
Requested Program Address
*
Please select first date choice
*
+
Requested Time
*
08:30a
09:00a
09:30a
10:00a
10:30a
11:00a
11:30a
12:00p
12:30p
01:00p
01:30p
02:00p
02:30p
03:00p
03:30p
04:00p
04:30p
05:00p
05:30p
06:00p
06:30p
07:00p
07:30p
-
Please select second date choice
*
+
Requested Time
*
08:30a
09:00a
09:30a
10:00a
10:30a
11:00a
11:30a
12:00p
12:30p
01:00p
01:30p
02:00p
02:30p
03:00p
03:30p
04:00p
04:30p
05:00p
05:30p
06:00p
06:30p
07:00p
07:30p
Please select a program (2 program max)
*
🛈
Fire Extinguisher Training (virtual options available)
Fire Evacuation Training (virtual options available)
Floor Warden Training (virtual options available)
Fire Puppet Show (indoor only and power source needed)
Senior Fire & Fall Talk (virtual options available)
Fire Mobile Smokehouse (Weather Permitting)
Career Day (virtual options available)
Health Fair (virtual options available)
Youth Fire Setters Program
Caregivers Course (5 hrs)
Fire Safety Talk
*
None
Fire Safety Talk (general information)
Mobile Home Fire Safety Talks
Homeless Shelter Fire Safety Talks
Close your Door Campaign
How many people will be in attendance (estimate)
*
Home Surveys
🛈
Yes, I need a home survey
No survey needed
How many levels in your home?
N/A
1
2
3
4
5
How many Bedrooms?
N/A
1
2
3
4
5
6
7
8
9
10
Additional comments
Due to the current pandemic, apparatus requests aren't available.