Name *

First Name

Last Name

Phone *

(###)

###

####

Location Address *

Miller Place Residence

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Date Requested *

MM

DD

YYYY

Type of service requested

Fire House Tour

Fire Prevention Meeting

CPR Class

School Event

EMS Request for Event

Request for Fire Police for Event

Disclaimer *

By checking this box, it is understood community outreach dates must be approved. A confirmation email will be sent if accepted. No event will be scheduled without approval. Only community events will be submitted for approval