Request Safety Demonstration

Thank you for your interest in Riverland Energy's free electrical safety demonstration. Please fill out the following information, and your presentation time will be confirmed as soon as possible. If you have any questions, please contact Jordan at 608-409-7063, or jlien@riverlandenergy.com.

Contact Person

Name of School or Group

Contact Person's Phone Number

Date of Presentation

Time Preferred

Second Choice of Date of Presentation

Second Choice of Time Preferred

Age of Audience

How many students/participants will be in attendance?

How many teachers will be in attendance?

Notes for the presenter (split in two groups, where to set up, etc.)

Location of Event

Address

City/Town

Safety Demo Request