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Please tell us your first and last name.

First Name

Last Name

What organization do you represent?

What type of organization are you?

Public Safety (Fire, Emergency Medical Services, Law Enforcement, Emergency Management)
Academic (2 or 4 year institution, Extension service affiliated with an academic instituation)
Community / Regional / State Non-Profit Organization with ties to Farming and Agricultural Activity
Other:

What is your organization's full mailing address?

Street Address 1

Street Address 2

City

State

Zip Code

What is your email address?

Email Address

What is the best daytime telephone number to reach you at?

Daytime Telephone

What is the best evening telephone number to reach you at?

Evening Telephone

Please explain why your organization wants to be a part of this program? How might you contribute to the overall goal of reducing injuries, illnesses, and fatalities in farming and agriculture in your community?

Orientation will consist of a Zoom session in February. Please outline what days/times generally work best for you to be able to attend a 2-3 hour orientation program.

Virginia Tech asks that each organizations using this program for outreach perform a minimum of 5 outreach sessions for the target audience over the next six months. Are you willing to commit to that goal?

Yes
No