* 1. Family Information

* 2. Two volunteers will be coming to your home between the hours of 9am-12pm on Saturday, August 3rd. Please have an adult home during those hours to ensure we can come to your house and install the equipment. If this is an issue, please let us know in the box below.

* 3. Please give the ages of the kids who live with you?

  Under 12 months 1-2 years old 3-4 years old 5-6 years old 8-12 years old 12+ years old
Child #1
Child #2
Child #3
Child #4
Child #5
Child #6

* 4. Which home safety equipment do you currently have? (Select all that apply)

* 5. Please tell us how you heard about the Safety Day?

* 6. Primary Language spoken in the home

* 7. A member of the "Building Safety on Your Block" team will be in contact the week of August 3rd to remind you of your involvement and to verify you'll still be able to participate.