• Number of Materials Needed

  Enter number of students needed and teachers using the materials in the boxes below. The selected booklet they will be receiving this year is Electrical Safety World (#38600).

• Number of Students
  Please enter a number greater than or equal to 1.
• How many teachers will be using these materials?

• Contact Information

• First Name*
• Last Name*
• Role (Check all that apply)*
  • Teacher
  • Para Professional
  • Principal/Vice Principal
  • Administrative/Office Assistant
  • Librarian
  • Volunteer
  • Parent (Homeschooling children)
  • Other
• School Name*
• District
• • Check if this is a homeschool
• Mailing Address*
• City*
• State*
  Select a stateNorth CarolinaSouth CarolinaTexasVirginia
• Zip Code*
• Phone*
• Email*
• This field is hidden when viewing the form
  P38600 Booklet Total (Students + Teacher)
• This field is hidden when viewing the form
  P75475 Pre Post Instruction Letter
• This field is hidden when viewing the form
  P74535 Teacher Guide with Answer Key
• This field is hidden when viewing the form
  P53925 Pre Post Tests

• Internal Use Only

• ID
• BRC Code
• Date
  MM slash DD slash YYYY
• This field is hidden when viewing the form
  project_category
  • school
  • contractor
  • first responder
  • other
• Phone
  This field is for validation purposes and should be left unchanged.