HomeMy WebLinkAboutip-req-form-helmet-bicycle-presACPHD/EMS Injury Prevention Program
Helmet/Wheeled Vehicles Safety
Presentation
Request Form
Interactive lessons that address injury prevention strategies. Lessons can be
differentiated to meet appropriate health education standards based on grade.
*Presentations are not available the last Monday and first Wednesday of every month*
Please circle the location the presentation will be conducted.
In-Class After School Program Recreation Center
Contact Information & Schedule
Contact Name: Location:
Location Address:
Phone Number: Email:
Estimated Attendance for Event:
Ages (or grades) of Attendance for Event:
1st Choice Date for Event:
2nd Choice Date for Event:
3rd Choice Date for Event:
Principal’s Name: *Principal Signature:
* If this presentation is being held at a school, the principal’s signature is required for your
application to be processed.
Please return request form to:
ACPHD/EMS
Injury Prevention Program
1000 San Leandro Blvd, 2nd Floor
San Leandro, CA 94577
Fax: 510-618.2099
Office: 510.618.2050
FOR OFFICE USE ONLY
Received:
Approved Date:
Confirmation Sent:
On Calendar:
IP Req Form Helmet Bicycle Pres.doc 6.10.2011