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2. Public Education Request Form
   York County Fire and Life Safety Personnel are happy to assist our citizens with valuable educational opportunities that will increase awareness and knowledge of fire, burns, and overall home and life safety. We have many public programs available. This form will help us meet your education needs. Please fill out all sections of the form. Our Public Educator will contact you within two business days. We look forward to serving you.
4. Name*
5. Date*
   Date
7. Email Address*
9. Address*
11. City*
12. State*
13. Zip Code*
15. Best Contact Phone Number*
16. Best Time to Call You*
18. Date of event
    Date of event

    Date of event

    On what date would you like to try to schedule your event?

19. Full Address of the Event*
21. Education Program Requested (Select at least one)*

    1. Children's Fire Safety Education Program
    2. Senior Safety Program
    3. Home Safety Survey
    4. Safety in the Workplace Program
    5. Car Seat Installation or Safety Check
    6. Smoke Alarm Assistance or Installation
    7. Fire Extinguisher Training
    8. Station Tour
    9. Apparatus Display
22. 
Leave This Blank:


24. 1. Receive an email copy of this form.
25. Email address

    This field is not part of the form submission.

26. Submit

* indicates a required field