Video Checkout Form Your Contact Information Name: Organization Name: Street Address (for UPS): City: State: Zip Code: Phone Number: Fax Number: Email Address: Check-Out Date: Return Date: The KTSRO Video Library is available to anyone free of charge. Checkout length is two weeks unless other arrangements have been made with KTSRO. All videos must be returned in the condition they were received. If videos are not returned or are returned in bad condition you will be held responsible for replacing that video to the KTSRO Video Library in a timely manner. Please send this form in along with the video list where you should have checked the titles you would like to checkout. I have read this loan agreement and understand the requirements outlined. If there are any changes in my/the organization’s plans, I will notify the Kansas Traffic Safety Resource Office immediately. By typing your name in the space provided, you are signing this agreement. Please contact our office at 1-800-416-2522 if you have any questions or if we can be of any assistance. Enter Your First & Last Name: Today's Date: Available Materials Place a check mark next to the items you would like to check-out from KTSRO. Alcohol Related Video Resources SMASHED: Toxic Tales of Teens & Alcohol (DVD) Material ID: A32,A33,A34 Toxic Tales of Teens and Alcohol. SMASHED pulls no punches in its graphic presentation of the devastating consequences of underage drinking and impaired driving. Focusing on the effects of impaired driving collisions when the victims do not die, it shows young crash victims from their arrival at the shock trauma facility and follows their progress over time. It features interviews with medical personal, the teens themselves, their friends, and their families. Length: 55 min. Driving Drunk: Your Choice? (VHS) Material ID: A43 Focuses on 4 real-life situations where someone made the decision to drive drunk, and shows the long-term effects of those choices. You'll meet two moms who lost a young adult son and daughter to drunk drivers. You'll meet a man responsible for his own single car crash. Now he lives with the result of his choice. Finally, you'll meet a young man who insisted on driving drunk in spite of efforts to stop him, killing a young mother and her child. Their stories will affect you too, and influence your choices. Length: 20 min. Alcohol Prevention Bingo (Game) Material ID: A51 An educational game for teens about alcohol prevention. Brandon Tells His Story (DVD) Material ID: A54,A55 You're about to meet a remarkable young man who has paid-and will keep on paying a terrible price for a stupid choice he made when he was seventeen. Brandon had a few drinks at a party, managed to drive his friends home, then wrapped his car around a tree. He spent the next two and a half months in a coma, the next two years in rehab. His speech is slurred, his walk is unsteady, his memory is permanently impaired. You'll see first hand Brandon's fight everyday to get his life back to where it was. You'll meet his friends and family, most of all, you see how many lives can be changed forever by one irresponsible decision. Length: 28 min. Motorcycle Safety Related Video Resources Riding Straight Module (VHS) Material ID: S48 Experience the effects of alcohol impairment with a sober mind- and no hangover! Kit contains: 1. Riding Straight Facilitator's Guide 2. Bronze label Fatal Vision Simulator Goggles 3. MSF Floor Tape 4. Riding Straight Video Kit (with Leader's guide). Sharing the Road: Intersection (DVD) Material ID: S49 This video on Sharing the Road is customized for three different audiences: one for teens, another for the general driving community and third for commercial drivers. It's about real people in real driving situations. Here are the characters who help tell the story: THE TEEN - Does her friends really have her best interests in mind? THE MOM-Multi-tasking leads to unforeseen events. THE TRUCK DRIVER- He need more coffee to get through the long day. THE DOC- Little did he know that his shift wasn't really over.
