Brain Injury Association of Mississippi
"Improving the quality of life for survivors of traumatic brain and spinal cord injuries and their families and
supporting programs designed to prevent brain injuries."

                                             Safety Fair
                                            2008 – 2009
                              Ride and Roll Questionnaire

Name of School:                                                                                                        
Physical Address:                                                                                                        
City:                                                                 Zip:                                                        
Principal Name:                                                                                                         
Phone Number:                                                                                                         
Fax Number:                                                                                                         

Total Number of Students in Attendance - Please identify number of Students in
each grade.

K – 3                                         1st                                           4th                          

K – 4                                         2nd                                          5th                         

K – 5                                         3rd                                          6th                         
                            

We are required to work with the principal (not staff).  Parents will receive a letter
with information about safety prevention, the importance of having their children use
the helmets, care of the helmets, and identification of the Mississippi Department of
Rehabilitation Services SCI/TBI Trust Fund.

The Ride and Roll educational program will be presented to the children, the children
who participate in the education workshop will be fitted with a helmet.  This will take
place on the date set up by the Brain Injury Association staff and the school Principal.

The Ride and Roll Presentation will be broken down into two groups for schools that
have 300 or more students in attendance.

We request a minimum of 12 volunteers to help fit the free multi – sport helmets.  
This helps the children to be fitted in a timely manner.   

The schools are set up on a first come first serve basis.  Time of the program for the
Ride and Roll injury and prevention is 9:00 a.m. at each school.

Materials needed from the school for the Ride and Roll Presentation include:  PA
System.   

List two dates for Ride and Roll Safety
Fair:                                                                         

Principal Signature (required):                                                                                         

For more information call Dana Pierce, Associate Executive Director at
601-981-1021 or toll free at 1-800-641-6442.  Please return directions to your
school with this questionnaire.
                             Ride and Roll Prevention Program
                        Brain Injury Association of Mississippi

Name of School:                                                                                                 

Date:                                                         Start Time:         9:00                                

On the date of the event, the staff will be meeting with large groups of children in two
different areas of the school.

Presentation Area:
One group will meet in the presentation area, learning about the brain and helmet safety,
which includes the following topics:
•        Where is the Brain
•        What does the Brain do
•        How should my helmet fit
•        Different types of helmets
•        Brain and Spinal Cord Injuries

The following supplies will be needed:
•        Large area (such as the gym or auditorium)
•        PA System


Helmet Fitting Area:
While one group is in the presentation, we ask that the youngest children go to the helmet
fitting first. In this area, the helmets will be broken down into 4 different stations in another
large room such as the gym or large classroom.  The presentation and helmet fitting CAN
NOT be in the same room.

Each station will consist of all size helmets.
Example:  At station 1, there will be a box of XS, SM, and XL helmets depending on what
was ordered and received.  

Four Classrooms can be fitted at the same time.  Each classroom will go to 1 of the 4
stations that will already be set up.  After each child in that classroom is fitted, the class
may return back to their room.  It is suggested that the teachers write the names of their
students on the helmets once back in the classroom. This allows for a continuous flow of
traffic.

NEEDS FOR THIS AREA:  12 VOLUNTEERS

AN ABSENTEE LIST WILL BE COLLECTED FROM THE SCHOOL OFFICE AT THE END
OF THE DAY TO ENSURE THAT EVERY STUDENT RECEIVES A HELMET.

Please sign and fax back to Brain Injury Association at 601-981-1039.

Thank you for your assistance with our program.  If our working together prevents one
brain injury in your school, it is worth all that we may do that day.

Principal Signature (required):