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): Previous Funding/Local Donors List any left over funds from last year and any local donors that have been secured. Name Amount Left over Funding: 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. Participating School Population(Round To Nearest 100): Number Of Months Participating (Maximum 6 months): 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. Enter Your First & Last Name: Today's Date:
