Helmet Safety Check Request Form Day and date of helmet check Location Preferred time Location address Location Address Address 2 Location City/Town Location State/Province - Select -AlabamaAlaskaAmerican SamoaArizonaArkansasArmed Forces (Canada, Europe, Africa, or Middle EastArmed Forces AmericasArmed Forces PacificCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFederate States of MicronesiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarshall IslandsMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPalauPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirgin IslandsVirginiaWashingtonWest VirginiaWisconsinWyoming Location Zip/Postal Code Requesting organization Contact person Phone Number Email Approximate number of attendees Age range of children attending event Where will our activity be located? Indoors Outdoors If outdoors, what is the rain plan? Your organization must meet the following criteria: Provide tables and chairs Receive delivery of helmets and other materials prior to event and deliver it to the event site. Return materials after the event. We will arrange pick up of the materials. Arrange for a designated support person for the day of the event. Registration for the helmet check is required. Once a helmet check date is confirmed, you will receive a registration information flyer to distribute to families. Minimum enrollment is 25. Having fewer than 25 registrants two days before the helmet check date will result in cancellation. In the event the helmet check is canceled, it is your responsibility to notify the registered participants. Note: St. Louis Children’s Hospital is providing a free community service to ensure the safety of the children in your area. We will fit a child's existing helmet or a new helmet can purchased for $11. To guarantee that every child’s helmet fits properly, St. Louis Children’s Hospital cannot sell helmets for children who are not present at your event. I understand that it is the responsibility of my organization to meet the above requirements. I understand that submitting this request does not guarantee St. Louis Children's Hospital's participation in this event.