Text size selector icon

SAFE Check Request Form

STOP! Have you submitted your agreement form? If not, click here to do that first!

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.

Total Funding Requested:

Funds will be distributed based on availability. To make additional requests, please fill out the Additional Check Request Form, which will require an expense report at the end of the school year.

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.

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