GWGVFD Fire Safety Reservation Request Form

This form may be submitted on-line, or printed out and mailed to: GWGVFD, 801 Russell Av., Gaithersburg, MD 20879.

Name of Event:
Name of Location:
Address 1:
Address 2:
City:
State:
Sponsoring Group:
Point of Contact (POC):
POC email:
POC Phone Number(s):	Work: Home: Cell: (At least one phone number is required)
Event Date:
Time (Start to Finish) (CANNOT EXCEED 4 hours on site):
Expected number of children ages 4-12:
Special needs children:	Yes No If yes, please comment:
Is there an electrical outlet within 50 feet of where the Fire Safety House will be located that can supply at least a 30-amp load:	Yes No Not Sure Note: This is needed to support air conditioning and lighting inside the FSH while in display mode.
If outside Gaithersburg, list the name(s) of other fire departments that you have contacted:

Donations are very much appreciated.
As a guideline, average donations by corporations is $250, and by schools $100. However, any donation amount is greatly appreciated. Please make checks out to the GWGVFD Fireman's Fund.