2. Community Outreach & Education Request Form
   The Coon Rapids Police Department values the opportunity to speak with community groups about safety, crime prevention and other topics relevant to modern policing. We will make every attempt to accommodate your request. Due to the number of requests and limited resources, please note that we may have to schedule alternate dates, or in some rare cases, we may not be able to honor your request. To request an appearance or speaker for your event, please complete this request form no less than 2 weeks prior to the event date. Please note that this form is a request, not a confirmation - the event is not confirmed until you have received confirmation/verification from our department.
4. Contact Information
6. Contact Person First Name*
   Please note in the "comments" box if the day-of contact will be different, along with their name and contact information.
7. Contact Person Last Name*
9. Email Address*
10. Phone Number*
12. Organization Type/Audience
14. Organization/Group Name *
16. Anticipated Number of Attendees*
    -- Select One --up to 1010-2525-5050-100100+
18. Audience Type*

    1. Seniors
    2. Business Professionals
    3. Civic Group
    4. Faith-Based Organization
    5. Teens
    6. School-Age Children
    7. Preschool Age Children
    8. Other (Specify Below)
20. Other
    Please specify the "other" audience type
22. Event Details
24. Presentation Date & Time *
    Presentation Date & Time Start Date

    Presentation Date & Time Start Time

    —

    Presentation Date & Time End Date

    Presentation Date & Time End Time
26. Duration *
    What is the time commitment for this event
28. Event Location & Address*
30. Choose a topic that suits your event (select all that apply) *

    1. Auto Theft Prevention
    2. Anti-Bullying
    3. Community Watch Team
    4. Crime Prevention Through Environmental Design (CPTED)
    5. Personal Safety/Self-Defense
    6. Workplace Violence/Active Shooter
    7. Preschool/Daycare Visit "Officer Friendly"
    8. Bicycle Safety
    9. Car Seat Safety

    1. Retail/Commercial Security
    2. Interacting with the Police
    3. Child Safety
    4. Identity Theft, Fraud & Scams
    5. Drug Awareness
    6. Prescription Awareness
    7. Police Department Tour
    8. Other (please explain in comments)
32. Purpose/Goals of Event*
34. Will this event be open to the public?*
    -- Select One --YesNo
35. Will audio/visual equipment be available?*
    -- Select One --ProjectorMicrophoneComputerWi-Fi/internet accessNone
36. Do you want us to promote your event?
    -- Select One --YesNo

    *This is subject to approval by our media team
37. Are you requesting a uniformed officer or marked squad car?*
    -- Select One --Uniformed officerMarked squadBothNone of the aboveNot required, but appreciated.
39. Comments
    Please note any additional information, for example: "other" topics, audience type, or anything you feel we should know.
Leave This Blank:


41. 1. Receive an email copy of this form.
42. Email address

    This field is not part of the form submission.

43. Submit

* indicates a required field