FSH Request Form | Blank Children's Hospital in Iowa
Blank Children's Hospital

Fire Safety House Request Form

If you'd like the Fire Safety House to visit your area for Fire Safety Education or for Severe Weather Training, please complete and submit the following form. 


REQUEST FORM:

TRAILER AVAILABILITY:

You may check the  availability of the Fire Safety House by viewing the public event calendar. Please note this calendar is updated weekly to add new events.  

TERMS AND CONDITIONS:

Please review the Terms and Conditions documents prior to submitting your request. By submitting an event request you agree to these Terms and Conditions.  

Fire Safety Education Terms and Conditions

Severe Weather Education Terms and Conditions

SUGGESTED DONATION:

Please know that while the Fire Safety House is available to use free of charge a donation is suggested. Donations of any amount help to keep the Fire Safety House program visiting communities in Iowa just like yours!  Donations of the following amounts assist with:

  • A $150 donation provides program supplies for a one day event
  • A $325 donation provides program supplies and fuel for a one day event
  • A $500 donation provides pay for program drivers, trailer maintenance and fully supports the trailer for a one day event 


PLEASE FILL IN ALL FORM BOXES - The form will not submit if you do not fill in all boxes. 

Important! * Required Fields (Please note all * fields must be completed in order for the form to successfully submit)

 Has the FSH been to your area before? *If yes, date or approximate date: Organization sponsoring the FSH visit *Contact person(s) * Daytime phone number (Please provide a phone number you can be reached at during daytime hours for any questions or updates we may have regarding your request.)* Cellphone number (Please provide the cell phone number you can be reached at for the day of your event.)*  Email address * Event address * City *Zip code *  County *If sponsoring organization is not a fire department, with what fire department will you be partnering for this event?(Partnership with a fire department is not required but is preferred.)Please list any additional sponsors:
 Type of event *
 Type of training * Name of school/event *
 Will you * Date * Start time * End time *Projected number of children *  Projected number of adults *How will the event impact/affect the children in your community? *By clicking submit, you acknowledge that you've read and agree to the Term and Conditions of Use.Please make sure ALL fields are completed before clicking submit. - If you do not receive the thank you page next your form did not submit due to empty fields.Will your organization be able to consider a donation to the Fire Safety House Program? If your organization is already a sponsor please fill in the box with "current sponsor"