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* 1. Please put your contact information

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* 2. Please pick your JCC

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* 3. Is your JCC a Redwoods client?

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* 4. What is your JCC's size of JCC (if known)

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* 5. Yes, I am interested in participating in the Pilot program and will commit the time:
- Take the 45-minute Benchmark & Protect self-assessment at the beginning of the initiative - by Sunday, June 25, 2017
- The Culture of Safety Pilot Program participants will have a call with The Redwoods Group to review their safety practices and protocols and together discuss the three areas of safety the JCC identified as goals to adopt throughout the course of the initiative.
- One-day in-person visit at their JCC with a Redwoods consultant in September 2017 focused on helping them achieve their goals and improve their culture of safety.
- Monthly one-hour check-in calls with a Redwoods consultant to receive guidance and answer questions as their JCC works towards improving its practices.
- One hour debrief at the end of the Initiative.
- Taking the 45-minute Benchmark & Protect self-assessment at end of the initiative (January 10-February 1, 2018.)

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* 6. Approximate number of Full Time Employees ( FTEs) at your JCC

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* 7. Approximate number of Part Time Employees ( PTEs) at your JCC

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* 8. Please identify three areas of safety you would like to address.

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