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2. To request an appearance or a speaker from the Winston-Salem Police Department, please complete this form at least 30 days in advance of your event. The Winston-Salem Police Department values the opportunity to speak with the community on safety and crime prevention. We will make an attempt to accommodate your request. Please note that we may have to schedule alternative dates.
   
   If you have questions or need additional information, please contact the Community Resource Unit at 336-773-7835.
   
   Anyone who submits a form should be aware that in accordance with the North Carolina Public Records law, found in North Carolina General Statutes chapter 132, his or her email address is considered public record.
4. Service Requested*
   -- Select One --Crime Prevention ProgramSecurity AssessmentNeighborhood WatchCoffee with a CopTea Time PartyPaw Patrol Educational ProgramChild Safety Seat Installation
6. Your Organization Name*
8. Type of Organization

   1. Business
   2. Civic
   3. Charity
   4. Church
   5. Neighborhood
   6. School
   7. Other
10. Type of Organization if Other
12. Event Date & Time
    Event Date & Time

    Event Date & Time
13. Requested Date & Time of Appearance
    Requested Date & Time of Appearance

    Requested Date & Time of Appearance
15. Description of the Event and What Information to Be Presented by the Winston-Salem Police Department*
17. Special Considerations
19. Event Address*
    Include details or directions.
21. Event Telephone Number
23. How many people do you expect at the event?
25. Audience Type

    1. Children under 13
    2. Children 13 to 18
    3. Adults
    4. Seniors
    5. Special Needs
27. Name of Contact Person*
29. Contact Person Address
31. City
32. State
33. Zip Code
35. Contact Person Email*
37. Contact Person Phone*
38. Contact Person Cellphone
Leave This Blank:


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

    This field is not part of the form submission.

42. Submit

* indicates a required field