Deadline for Application: March 1

Section 1

Describe one program or activity that you felt was the most beneficial to the children in your local unit and/or community concerning their health and safety.

______________________________________________________________________________

Section 2

REGION: ________________________________

Entering the Health and Safety Award Program is optional although we encourage all local units to participate. This information will be used to assess local needs and to develop health and safety programs, activities and conferences that address current health and safety issues.

Please return this application by March 1 to the Hawaii State PTSA:

Hawaii State PTSA
P. O. Box 22878
Honolulu, Hawaii 96823-2878

PLEASE CHECK ONE:

Elementary () Middle () High School ()

PLEASE TYPE OR PRINT CLEARLY:

School Name ____________________________________________________________

PTSA Unit President ______________________________________________________

Health and Safety Chair ____________________________________________________

Address ________________________________________________________________

Phone Number_______________________ Email _______________________________

Section 3

The following are ways to identify health and safety issues within your school community. Please check those which you have used.

___Hawaii State PTSA Newsline___Parent Survey

___Our Children Magazine___PTSA Goal Setting Meeting

___Local Newspaper___School Staff Meeting

___Magazine Articles___PTSA Regional Training

___Meeting With Principal___PTSA Meetings

___Other (please explain) ______________________________________

Section 4

In which of the following safety categories did you provide programs, newsletter articles, flyers and other health and safety information. (circle all that apply)

Hurricane Preparedness/Child Car Seats

Pedestrian Safety/Bicycle Safety

Rollerblading/Fire Protection

Emergency Preparedness/Playground Equipment

Toxic/Hazardous Waste/Seat Belts

Bus Safety/Home Safety

Skateboard Safety/Teenage Pregnancy

Fingerprinting/Campus Violence

Gang Prevention/Recycling

Drug Prevention/HIV/Aids Education

Self Esteem/Nutrition

Other (please specify) ________________________________________________________________________

Section 5

Attach to this form a month by month list of programs or activities that you or your PTSA/PTA attended, initiated or sponsored that promoted health and safety in your school/community. So that we can acknowledge your full year of work, please include a description of the activities/programs that are planned for March through June.