Mobile Safety Van Event Request

To request the Children’s Hospital Mobile Safety Van to attend your scheduled event, please provide the following information.

Please note:The Mobile Safety van is not available:November 15 - March 17.

*indicates a required field.

*Date:
*Time:
*Location:	Please include full address
*Event Name / Sponsor:
*Contact Name:
2nd Contact Name:	Please list contact who will be on-site for event
*联系电话:
*Email:
*Expected Number of Attendees:
*Target Population:
*Focus of Event:	Please specify what topics/areas of interest will be featured
*Other Organizations in Attendance:
*Advertising for Event:
*Is this an outdoor event?:	Yes No
*Requested Topic:	Please specify topic/areas of interest you are requesting from OSF Children's Hospital
Set-Up Requirements PARKING: Van dimensions: 26 feet long; 10 feet wide • Requires clearance of at minimum 11 feet • Requires equivalent of 4 parking spaces for full set-up • Uses 30 amp/ 125 volt RV outlet (3 prong plug)
*Is there access to an external electrical outlet?:	Yes No
What is the approximate distance to parking location?:
Is there outdoor lighting available? (for evening events only):	Yes No
Additional Information or Comments:

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Set-Up Requirements