Please fill out this request form to request a display or presentation. Are you requesting a presentation or a display? Presentation 90 minute in-person or virtual educational session on chosen topic. This option is best for a classroom setting. Display Interactive display/booth addressing chosen topic(s). This option is best for community events. 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 - None - 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 six to eight weeks prior to event date to schedule staff to work in the community.- Event attendees must be parents with young children or professionals who make referrals for parents with young children.- Event organizers will provide a least two tables for this display. Requested Presentation Child Passenger Safety Basics Safe Sleep for Babies, 0-12 Months Requested day and date of presentation Preferred time of presentation Alternative day and date of presentation Alternative time of presentation Event format In-person Virtual Requesting organization Name of event location Address Address Address 2 City/Town State/Province - None - 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 Event planning contact person Contact phone number E-mail address Contact person for day of presentation Contact phone number for day of presentation Number of expected attendees Maximum number of attendees Age range of children in the families attending Your organization must meet the following criteria:- Presentations should be requested at least four to six weeks in advance.- Registration for the presentation is required. Organization must provide names, addresses, and emails of those in attendance.- Minimum enrollment is six. - This presentation is intended for parents only. - Presentations are 90 minutes long, which includes time for questions and answers.- This will be a PowerPoint presentation.- In the event the presentation is canceled, it is your responsibility to notify the registered participants.- An evaluation link will be provided to participants, and the results will be shared with organizer.- If you choose a virtual presentation, you must provide the meeting link unless BJC agrees to provide a Microsoft Teams meeting link. - Please note, presentations cannot be recorded. Boxes below must be checked prior to submitting the request. I understand that it is the responsibility of my organization to meet the above requirements I understand submitting this request does not guarantee the scheduling of this presentation Leave this field blank
Please fill out this request form to request a display or presentation. Are you requesting a presentation or a display? Presentation 90 minute in-person or virtual educational session on chosen topic. This option is best for a classroom setting. Display Interactive display/booth addressing chosen topic(s). This option is best for community events. 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 - None - 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 six to eight weeks prior to event date to schedule staff to work in the community.- Event attendees must be parents with young children or professionals who make referrals for parents with young children.- Event organizers will provide a least two tables for this display. Requested Presentation Child Passenger Safety Basics Safe Sleep for Babies, 0-12 Months Requested day and date of presentation Preferred time of presentation Alternative day and date of presentation Alternative time of presentation Event format In-person Virtual Requesting organization Name of event location Address Address Address 2 City/Town State/Province - None - 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 Event planning contact person Contact phone number E-mail address Contact person for day of presentation Contact phone number for day of presentation Number of expected attendees Maximum number of attendees Age range of children in the families attending Your organization must meet the following criteria:- Presentations should be requested at least four to six weeks in advance.- Registration for the presentation is required. Organization must provide names, addresses, and emails of those in attendance.- Minimum enrollment is six. - This presentation is intended for parents only. - Presentations are 90 minutes long, which includes time for questions and answers.- This will be a PowerPoint presentation.- In the event the presentation is canceled, it is your responsibility to notify the registered participants.- An evaluation link will be provided to participants, and the results will be shared with organizer.- If you choose a virtual presentation, you must provide the meeting link unless BJC agrees to provide a Microsoft Teams meeting link. - Please note, presentations cannot be recorded. Boxes below must be checked prior to submitting the request. I understand that it is the responsibility of my organization to meet the above requirements I understand submitting this request does not guarantee the scheduling of this presentation Leave this field blank
