Form Center

2. 
3. Kinston Department of Fire and Rescue
   P. O. Drawer 339, 401 E Vernon Avenue Kinston, North Carolina 28502 Office Phone: 252-939-3164 Fax Phone : 252-939-3157
5. Fire Prevention/Public Education/Community Interaction/Relations Request Form
7. Requester Information
8. Date of Request*
   Date of Request
10. Name of Requester:*
11. Middle Name:
12. Last Name:*
14. Address:*
16. City:*
17. State:*
18. Zip Code:*
20. Contact Phone Number:*
21. Email Address:*
23. Information of Event Requested
25. Date of Event:*
    -- Select One --JanuaryFebruaryMarchAprilMayJuneJulyAugustSeptemberOctoberNovemberDecember
26. Day:*
    -- Select One --01020304050607080910111213141516171819202122232425262728293031
27. Year:*
    -- Select One --2017201820192020202120222023202420252026202720282029203020312032203320342035203620372038203920402041204220432044204520462047
29. Time:*
    -- Select One --8:00 AM9:00 AM10:00 AM11:00 AM12:00 PM1:00 PM2:00 PM3:00 PM4:00 PM 5:00 PMOther
30. If Other is selected please list Time Requested:
32. Number of Citizens Attending
34. Youth (Ages 1 to 18 Years Old):
35. Adults (Ages 19 to 49 Years Old):
36. Seniors (Ages 50 and Older):
38. Static Truck Display
    
39. Classroom Visit
    
40. Community Interaction/Relations
    
41. Community Service Assistance
    
43. Is the Event Requested to take place at a different location other than the Kinston Department of Fire & Rescue?*

    1. Yes

    1. No
44. If Yes was checked, please fill out the Address of the Event and select Requested Services from Out in Public Selections.

    If No was checked, please select the Fire Station Requested for the Event and select Requested Services from the Kinston Department of Fire & Rescue Selections.
    (Note: If Fire Safety Puppet Show, Meet Sparky the Fire Pup, or Meet the Fire Administration/Fire Chief are selected the Event must take place at Fire Station 1 [Headquarters]).
46. Address of the Event:
48. City:
49. State:
50. Zip Code:
52. Requested Services for Fire Companies out in the Public:

    1. Static Truck Display
    2. Informational Seminar
    3. Business/Group/Public Meeting

    1. Classroom Visit
    2. Community Interaction Appearance
    3. Community Services Assistance (Working Party to assist the Community Members with a Community Oriented interaction such as Flagpole Lanyard repair [only if requester purchases the parts], Community Clean-up, Preparation for a Large Community Event)
54. Select Fire Station for the Planned Event:
    -- Select One --Fire Station 1 (Headquarters) 401 E Vernon Avenue, Kinston, North Carolina 28501Fire Station 2/3428 Carey Road, Kinston, North Carolina 28504Fire Station 3/1247 Hillfarm Road, Kinston, North Carolina 28504
56. Requested Services at the Kinston Department of Fire & Rescue:

    1. Fire Safety Puppet Show
    2. Stop, Drop, and Roll Demonstration/Meeting with Sparky the Fire Pup (Robot)
    3. Meeting the Fire Administration/Fire Chief
    4. Fire Apparatus and Equipment Demonstration

    1. Fire Extinguishers Class
    2. Exit Drills In The Home (E.D.I.T.H.) Preplanning/Education
    3. Fire Prevention Safety Tips Handouts
    4. Fire Station Tour
58. Puppet Shows
    
59. Fire Pup (Character)
    
60. Fire Station Tours
    
61. Sparky the Fire Pup (Robot)
    
Leave This Blank:


63. 1. Receive an email copy of this form.
64. Email address

    This field is not part of the form submission.

65. Submit Submit and Print

* indicates a required field