BPSE / SRTS Request Form
Bicycle & Pedestrian Safety Education (BPSE) Program
Safe Routes to School (SRTS) Program

Maine’s Bicycle and Pedestrian Safety Education (BPSE) program is an innovative partnership of the Bicycle Coalition of Maine (BCM) and the Maine Department of Transportation. The program provides:

1) bike and pedestrian safety instruction to children and adults via presentations and experiential riding programs,
2) management of the Maine Safe Routes to School (SRTS) program to encourage students to bike and walk to school,
3) education and information to communities about program, policy, and infrastructure options to improve walking and biking conditions, and
4) education to all roadway users about how to safely, legally and courteously share the road.

Please complete the form below to request BPSE and/or SRTS program assistance.

HELMETS: BCM can provide Aerius V19 helmets at $14/helmet including s&h. These are have visors, turnbuckles, and are well constructed. Use the "Additional Information" field at the bottom of the below form to indicate if you would like additional information about purchasing helmets. For a cheaper helmet visit prorider.com

**REQUIREMENT** In hosting an instructor we ask that you provide feedback through a post-visit evaluation form, which will be emailed to you following completion of the safety education event. This feedback is an important to continuing & improving BCM's education program.

**NOTE** We depend on the availability of instructors in your area to provide you with programming and make every effort to fill all requests. NOT EVERY REQUEST CAN BE COVERED WITH AN IN-PERSON VISIT.
Full Name *
First Last
Your answer
Email *
Your answer
Phone Number *
Your answer
Position *
E.g., Teacher, Nurse, Office Manager
Your answer
Organization / School *
Your answer
Street Address *
where event will take place
Your answer
City *
where event will take place
Your answer
Zipcode *
where event will take place
Your answer
County *
where event will take place
Educational Event Type *
Select all that apply.
Define the specific need for this request *
E.g., Students have demonstrated unsafe walking / cycling practices, there has been an accident, dangerous infrastructure exists near the school, encourage more people to ride/walk, ***Be specific when possible to show why people NEED this safety training***
Your answer
Estimated Number of Participants (total) *
Due to the interactive nature of the presentations, we strongly recommend that student groups of more than 45 be broken into smaller units of similar age. If you are considering an assembly-type event, please provide details of your event in the "Additional Info" field below.
Your answer
Estimated Number of Presentations
Due to the interactive nature of the presentations, we recommend presenting to groups of similar age numbering no more than 45 per presentation (20-30 is optimal, like a class or a scout troop etc.). Please estimate the number of groups/classrooms of that size needing a presentation. If you are considering an assembly-type event, please provide details of your event in the "Additional Info" field below.
Your answer
General Age Groups / Grades *
Specific Age Groups / Grades *
E.g., kindergarten, grades 4-6, adults, all ages, adults, seniors
Your answer
What date(s) and time(s) are available for this event? *
Please provide info on when you need program assistance. Be as specific as you can. Note that large groups (eg entire schools) may need multiple visits by program representatives. FINAL SCHEDULING IS DEPENDENT ON INSTRUCTOR AVAILABILITY, but we will make every effort to accommodate your preferred date/time.
Your answer
Have you hosted a BPSE instructor in the past?
Select Yes or No. If yes (and if you remember!) include the instructor's name in the "other" field.
Additional Information
Any other info you want to include or questions you need to ask. To request additional info about our helmet program. If you're thinking of an assembly or other atypical event, please provide details here.
Your answer
Safe Routes to School (SRTS) Encouragement & Planning Program
The SRTS Program offers technical assistance to help communities host encouragement & incentive activities to get more students walking and biking, work on safety enforcement, explore the Maine Walking School Bus Program, and/or do evaluation of local barriers to safe walking and bicycling and plan for improvements. For more information on Safe Routes to School and its services, visit http://www.bikemaine.org/education-safety/youth-education

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