Request Injury Prevention Staff for an Event Children's Injury Prevention Staff are available for Programs & Events. To request education materials and/or staff at your event, please submit a request using the form below. * Asterisk indicates a required field. Event Request Presentation Booth Health Fair Community Event Other If other, please specify Focus Area Bike Helmet Safety Child Passenger Safety Period of PURPLE Crying Home Safety ThinkFirst Safe Kids of Douglas County Other If other, please specify Organization/Agency Name* Contact Person* First Last Phone* Email* Organization Address* Street Address Address Line 2 City Alabama Alaska American Samoa Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Guam Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Northern Mariana Islands Ohio Oklahoma Oregon Pennsylvania Puerto Rico Rhode Island South Carolina South Dakota Tennessee Texas Utah U.S. Virgin Islands Vermont Virginia Washington West Virginia Wisconsin Wyoming Armed Forces Americas Armed Forces Europe Armed Forces Pacific State ZIP Code Event Name* Date of Event* MM slash DD slash YYYY Event Start Time : Hours Minutes AM PM AM/PM Event End Time : Hours Minutes AM PM AM/PM Event Details* Building Name (if applicable) Event Address Street Address Address Line 2 City Alabama Alaska American Samoa Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Guam Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Northern Mariana Islands Ohio Oklahoma Oregon Pennsylvania Puerto Rico Rhode Island South Carolina South Dakota Tennessee Texas Utah U.S. Virgin Islands Vermont Virginia Washington West Virginia Wisconsin Wyoming Armed Forces Americas Armed Forces Europe Armed Forces Pacific State ZIP Code This event will be held (select one)* Inside Outside Has the Children's Injury Prevention Staff participated in this event before?* Yes No If yes, when? Target Audience* Adults Children Both Adults and Children Medical Professionals Health Agency Staff Anticipated Number of Participants Please provide day-of-event details, such as set-up time, driving/parking directions, and contact information (e.g.cell phone number) Children’s Hospital & Medical Center’s participation is dependent on resources, scheduling and staff availability. Completing this event request form does not guarantee participation. A staff member from Children’s Hospital & Medical Center’s Trauma Department will contact you to follow up on your submitted request. Please check the box below:
