HomeMy WebLinkAboutsipp-presentation-request-form-06-18-2025Senior Injury Prevention Presentation Request Form
First Name:Last Name:
Organization Name:
Organization Website:
Contact Person:
Phone Number:Email:
Anticipated Number of Attendees:
How do you plan to promote this presentation to the members of your organization?
Proposed Presentation Start Time:
1st Choice: 2nd Choice:3rd Choice:4th Choice:
To submit this form: If you are using Internet Explorer, click the submit button and it will be attached to your email client. If you are using Chrome/Firefox, click the print button, change the print destination to "Save as PDF" and save the form to your computer and then email it to: Kim.Chung2@acgov.org
Which of the presentations listed below are you interested in hosting? (check all that apply):
Fall Prevention Presentation The discussion will focus on contributing factors that cause falls. Areas that will be discussed are Changing Behaviors, Nutrition & Medication Management, Fitness, and Home Safety Checklist.
Personal Emergency Preparedness PresentationThe discussion will focus on the preparations older adults can make so that they will be organized and equipped to cope with emergency situations.
No preference
Tell us a little about your organization and its primary function:
Preferred presentation delivery format:
IInn--PPeerrssoonn Virtual
Proposed Presentation Dates (List in order of preference):