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Presentation Request Form

Purpose of Request or Event:

Participants: Court personnel
Firefighters
Police officers
EMS
Medical personnel
Senior citizens
General public
Teachers/Counselors
Students, grade level:    
Other:    

Projected number of attendees:

Presentation held in conjunction with other activities or event? No
Yes

If yes, specify event and other participants:

Publicity/Advertising for event? No
Yes

If yes, please specify:

Presentation Requested: Burn Injuries
Trauma Injuries
Senior Safety
Fire Safety & Prevention
Hazard House
Trauma Burn Booth Display
Trauma Burn Program Information & Referral Process
Straight Talk

Other:    
Presentation Length: 1/2 - 1 hour
1 - 2 hours
Other:    

Preferred Date and Time of Presentation:

Presentation Equipment Available:

Requesting Group/Agency:

Contact Person:

Phone:

Fax:

E-Mail:

Program Location Street address:

City:

ZIP code:

Other comments:

Thank you for your request! Messages generated by this form are read only on weekdays during business hours. If your message is received after hours or on a weekend, it will be processed the next business day. If you experience any issues with the submission of this form, please contact traumaburn@umich.edu.

It is not possible to assure security on this system so do not send confidential information using this medium.


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