Text size selector icon

SAFE Program Check Request Form

Check Information
Shipping Information

Please enter the shipping information for where the check should be mailed, in the fields provided below.

Local Donors

List all donors and/or diversion dollars that have been secured.

 
Name
Amount
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.

 
Description
Amount
($25 x 1/100 x Participating School Population x Number Of Months Participating) + (Other Expenses - Total Donor Funding) = 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 signing this agreement.

Change the page font size to large Change the page font size to medium Change the page font size to small