Equipment Order Form

Available Equipment

The following equipment is available for request. Please download and read the appropriate file to confirm you understand your responsibilities for each type of equipment you have requested. Place a check mark in the box next to that equipment to select it.

You must be able to arrange pick-up and return of equipment based on availability. In order to request the Bike/Pedestrian trailer or Safe Kids van, a representative from a municipality, state government agency, or public safety agency must be available to transport or tow the trailer/van.


		Bike and Pedestrian Safety Trailer
		Bucklebear Costume
		Hot Cars Display
		Medicine Board Display
		Safe Kids Van
		Spot the Tot Rug

Request Information

Name of Event*

Date Event Begins*

December 2018

Date Event Ends*

December 2018

Time Event Starts

Hours*

Minutes*

am / pm*

First Name*
Last Name*
Phone* xxx-xxx-xxxx
Cell Phone* xxx-xxx-xxxx
Email*
Name of Safe Kids Affiliation:*
Address*
City*
State*

Zip*
Location of Event:*
County of Event*

Address of Event*
Event City*
State*

Zip*

Responsible Party Transporting Van/Trailer - First, Last and Agency Names are required when requesting Van/Trailer, otherwise may leave blank.

First Name
Last Name
Agency

Comments

I agree:

to coordinate with NC DOI-OSFM Injury Prevention staff member on picking up or having equipment delivered.
that the equipment will be used for its intended purpose in a safe and proper manner.
that I have read and printed instructions and requirements for requested equipment.
to inspect all equipment in the presence of an NC DOI-OSFM staff member at the time of check-out and check-in, to determine that the equipment is in working order and that nothing is missing or damaged.
to return all equipment in the condition it was received.
to either ship item or make arrangements with NC DOI-OSFM Injury Prevention staff member to have item returned within 4 business days.
to pay the cost of any piece or part of equipment that is lost, stolen or damaged while the equipment is in my care.
to report any damages, defects or problems with the equipment that is checked out under my name, when it's returned.