SAFE Check Request Form STOP! Have you submitted your agreement form? If not, click here to do that first! Check Information Make Check Payable To: County Name: Name Of School: SAFE Sponsor's Name: Sponsor's Phone Number (000-000-0000): Email Address: Send A Copy Of This Completed Form To Email Address: Shipping Information Please enter the shipping information for where the check should be mailed, in the fields provided below. School/Agency Name: Address: City: State: Zip Code (5 or 9 digits): Local Donors List all donors and/or diversion dollars that have been secured. Name Amount Donor #1: Donor #2: Donor #3: Donor #4: Donor #5: Donor #6: Total Funds: Expenses When you fill out the number of students and months below, that will generate the dollar amount for the monthly prize give away. It is based on this formula: $25 x (1/100 x Participating School Population) x Number of Months Participating. The additional request boxes should be filled out if you are requesting anything other than the monthly prize amounts. Participating School Population(Round To Nearest 100): Number Of Months Participating (Maximum 8 months): Description Amount Additional Requests #1: Additional Requests #2: Additional Requests #3: Additional Requests #4: Additional Requests #5: Additional Requests #6: Additional Request Comments: Total Funding Requested: All or a portion of the requested funding will be awarded. Other requests may be evaluated on February 1st and awarded based on availability of funds. I understand by submitting this form and requesting a grant from the Kansas Traffic Safety Resource Office and the Kansas Department of Transportation, I have committed to implement the SAFE program to its completion. Submitting the final survey marks completion of the program. Failure to complete the program will result in returning the grant dollars received. By typing your name and entering the date in the fields provided, you are e-signing this agreement. Enter Your First & Last Name: Today's Date:
