HomeSCI FiberLifeline ProgramLifeline Program Consent Form Font Size: Share Share on FacebookShare on X (Twitter)Share on PinterestShare on LinkedinShare on Email Feedback Print
Lifeline Program Consent Form Live Line Safety Demonstration Request Form InstagramThis field is for validation purposes and should be left unchanged.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 No How did you hear about this demonstration?Organization/Event InformationGroup or Organization TypeK-12Emergency ServicesCommunity GroupsOtherPlease explain your group or organization type.How many people will be attending?Minimum number of attendees: 25What 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 DetailsDate Time Hours : Minutes AM PM AM/PM Alternative Date Alternative Time Hours : Minutes AM PM AM/PM Location Address Street Address Address Line 2 City State AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific ZIP Code Demonstration Area DetailsWill 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 No Please submit photo of area you would like to have the demonstrationPlease 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. Waiver(Required) Waiver(Required) I understand that, as the organizer listed on this application, I am responsible for the safe setup of the venue and participants. SCI REMC is only responsible for its equipment and onsite employees during the demonstration.
