Lifeline Program Consent Form

Live Line Safety Demonstration Request Form

First Name(Required)

Last Name(Required)

Phone(Required)

Email(Required)

Name of Organization(Required)

Are you an SCI REMC member?(Required)

Note: Non-members or events located outside our service area may be subject to a $500 pre-charge for demonstrations.

Yes

How did you hear about this demonstration?

Organization/Event Information

Group or Organization Type

Please explain your group or organization type.

How many people will be attending?

Minimum number of attendees: 25

What is the age range for those attending the demonstration?

Please describe the organization or event where you would like the demonstration to take place.

Organization/Event Details

Date

Time

Alternative Date

Alternative Time

Location Address

Street Address Address Line 2 City State ZIP Code

Demonstration Area Details

Will the demonstration happen indoors or outdoors?

Indoors

Outdoors

Is there an available outlet near the demonstration area that SCI can use to power a speaker?

Note: If an outlet is not available, SCI REMC can utilize its generator.

Yes

Please submit photo of area you would like to have the demonstration

Please note that if you would like the presentation to be outside, we prefer the area to be paved or smooth. Gravel and grass surfaces can pose challenges.

Max. file size: 128 MB.

Lifeline Program Consent Form

Live Line Safety Demonstration Request Form

Organization/Event Information

Organization/Event Details

Demonstration Area Details

Main Office

Office Hours

Contact Info

Social Media

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