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Host Agency Information and Point of Contact

Notice
Do not include any sensitive information on this form or (if applicable) files uploaded to this form. Sensitive information includes, but is not limited to, social security numbers, driver’s license numbers, bank account information, routing numbers, medical information, passport numbers, or passwords.
POC Name*
Email Address*
Agency Name*
Address*
City*
State
Zip Code*
Day Phone Number*
Mobile Number
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Class Logistics Information

Course Requested*
1. K-12 Lockdown and Security Awareness Training Classroom (2 hours)
2. K-12 Lockdown and Security Performance Level - Drills (2 hours)
3. K-12 Transportation Security (3 hours)
4. School Evacuation for Radiological Emergencies (2 hours)
5. School Evacuation for Radiological Emergencies - Transportation worker (1 hour additional, 3 hours total)
Course Location Name*
Room Number or Name*
Course Location Address*
City*
State*
Zip Code*
Number of Sessions Requested*
Max # of Participants (each Session)*
Provide at least two date proposals for each session requested. Provide the beginning time and an ending time for the class.
Session 1 Date Request (1st Preference)*
Session 1 Date Request (1st Preference) Start Date
Session 1 Date Request (1st Preference) Start Time
—
Session 1 Date Request (1st Preference) End Date
Session 1 Date Request (1st Preference) End Time
Session 1 Date Request (2nd Preference)*
Session 1 Date Request (2nd Preference) Start Date
Session 1 Date Request (2nd Preference) Start Time
—
Session 1 Date Request (2nd Preference) End Date
Session 1 Date Request (2nd Preference) End Time
Completed date requests for multiple sessions only if multiple sessions are being requested.
Session 2 Date Request (1st Preference)
Session 2 Date Request (1st Preference) Start Date
Session 2 Date Request (1st Preference) Start Time
—
Session 2 Date Request (1st Preference) End Date
Session 2 Date Request (1st Preference) End Time
Session 2 Date Request (2nd Preference)
Session 2 Date Request (2nd Preference) Start Date
Session 2 Date Request (2nd Preference) Start Time
—
Session 2 Date Request (2nd Preference) End Date
Session 2 Date Request (2nd Preference) End Time
Session 3 Date Request (1st Preference)
Session 3 Date Request (1st Preference) Start Date
Session 3 Date Request (1st Preference) Start Time
—
Session 3 Date Request (1st Preference) End Date
Session 3 Date Request (1st Preference) End Time
Session 3 Date Request (2nd Preference)
Session 3 Date Request (2nd Preference) Start Date
Session 3 Date Request (2nd Preference) Start Time
—
Session 3 Date Request (2nd Preference) End Date
Session 3 Date Request (2nd Preference) End Time
NOTE: When booking the class location, please include at least 30 minutes before the class and 30 minutes after the class concludes for setup and cleanup. Don't include this expanded time in your submission above. We only want the time of the actual class, but we want to remind whoever books the venue that they need to book the room for extra time.
Session Schedule Notes
Provide notes that you think we may need to know for scheduling.
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