Safety Stop Display Request Form Requested Topic (choose up to 4) Car Seats Bicycle Helmets Home Safety Sleep Safety Name of the event Event date Event start time Event end time Requesting organization Name of event location Address of event location Address of event location Address 2 City/Town State/Province - Select - Alabama Alaska American Samoa Arizona Arkansas Armed Forces (Canada, Europe, Africa, or Middle East Armed Forces Americas Armed Forces Pacific California Colorado Connecticut Delaware District of Columbia Federate States of Micronesia Florida Georgia Guam Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Marshall Islands 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 Palau Pennsylvania Puerto Rico Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virgin Islands Virginia Washington West Virginia Wisconsin Wyoming ZIP/Postal Code Will our activity be located outside? - Select - Yes No If our activity will be outside, what is the rain plan? Event planning contact person Phone number E-mail address Contact person for day of event Cell phone Date last held Number of attendees Your event must meet the following criteria: - Due to the hospital’s demanding staffing needs, the request must be completed at least 6-8 weeks prior to event date to schedule staff to work in the community. - Event must have been held previously, with a minimum of 100 attendees. - Event attendees must be parents with young children or professionals who make referrals for parents with young children. - Event organizers will provide a least 2 tables for this display. I understand that it is the responsibility of my organization to meet the above requirements I understand that submitting this request does not guarantee St. Louis Children's Hospital's participation in this event
