Bike Helmet Application

Application for Bicycle Helmets
Thank you for your interest in providing bike helmets to Upstate children! Please fill out the form below! All fields marked with an * are required. When you have completed the form, click 'Submit' and someone will be in touch with you shortly.
Name of Organization
* Name of Person Making Request
* Street Address
Address Line 2
* City
* State
* Postal/Zip Code
* County
* Phone Number
Fax Number
Email Address
* Type of Organization Applying:
* How many bike helmets are you requesting?
* Please list the ages and corresponding genders of each child you are requesting helmets for. If there are more than 1 child in each age/gender group, please designate quantity. See example.	ex. 5 yr Female, 3 x 6 yr Male, 3 x 6 yr Female, etc.
* What type of event are you holding? If you are not requesting helmets for a specific event, please put 'n/a.'
* Has the organization applying ever received helmets from Safe Kids Upstate?
If you answered yes to the question above, when?
* Enter Auth Code

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