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CSFD: Prevention Program Request Form
Name of Organization:

Contact Name:

Phone Number:

E-Mail Address:

Number of Participants:

Age Range of Participants:

Would you like for the prevention program to take place at:
If the program will take place at a fire station, please select which you'd prefer:
If the program will take place at your facility, would you like a fire engine to visit as well?
If the program will take place at your facility, please provide the physical address:

Is there any specific fire safety topic that you or your group would like to learn more about?
Yes, please describe:

Prevention programs can be scheduled during the following times: Monday-Friday, 9 a.m.-12 p.m., 1-4 p.m. and 7-9 p.m. The fire department will make every effort to accommodate your request but cannot guarantee that the times requested will be available.

Please provide three desired program dates and times.




Please note any additional information that may be helpful when scheduling your request:

I, for myself and my organization, school or group, release and agree to hold harmless for any and all purposes the City, its agents, officers, employees, volunteers and assigns from any and all liabilities, claims, demands, or injuries that may be sustained by me or my organization, school or group members in attendance as a result of or arising from me or my organization, school or group, participating or performing activities for or in the College Station Fire Department.*
I, for myself and my organization, school or group, hereby accept and assume all risk and responsibility for any harm, injury, or damage, to myself or my property, while my organization, school or group and I are on City-owned property or any other property and while participating or performing activities for or in the College Station Fire Department.*
I hereby give the City the right to photograph, televise, film, and sound record me and my organization, school or group acts, appearances and utterances of me and those from my organization, school or group and to use any descriptive words or names, including my name or my organization, school or group name in conjunction therewith and without limit as to the time, to produce and reproduce the same or any part thereof by any method and to use for any purpose which the City deems proper. All such photographs, teletapes, films and sound recording shall be the exclusive property of the City and I and my organization, school or group hereby relinquish all rights, title, and interest therein.*
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