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 -AlabamaAlaskaAmerican SamoaArizonaArkansasArmed Forces (Canada, Europe, Africa, or Middle EastArmed Forces AmericasArmed Forces PacificCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFederate States of MicronesiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarshall IslandsMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPalauPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirgin IslandsVirginiaWashingtonWest VirginiaWisconsinWyoming ZIP/Postal Code Will our activity be located outside? - Select -YesNo 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 Leave this field blank
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 -AlabamaAlaskaAmerican SamoaArizonaArkansasArmed Forces (Canada, Europe, Africa, or Middle EastArmed Forces AmericasArmed Forces PacificCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFederate States of MicronesiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarshall IslandsMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPalauPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirgin IslandsVirginiaWashingtonWest VirginiaWisconsinWyoming ZIP/Postal Code Will our activity be located outside? - Select -YesNo 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 Leave this field blank
