Request Injury Prevention Staff for an Event Children's Injury Prevention Staff are available for Programs & Events. To request education materials and/or staff at your event, please submit a request using the form below. * Asterisk indicates a required field. Event Request PresentationBoothHealth FairCommunity EventOther If other, please specify Focus Area Bike Helmet SafetyChild Passenger SafetyHome SafetySafe Kids Douglas CountyOther If other, please specify Organization/Agency Name* Contact Person* First Last Phone* Email* Organization Address* Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Event Name* Date of Event* MM slash DD slash YYYY Event Start Time : Hours Minutes AMPM AM/PM Event End Time : Hours Minutes AMPM AM/PM Event Details* Building Name (if applicable) Event Address Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code This event will be held (select one)* Inside Outside Has the Children's Injury Prevention Staff participated in this event before?* Yes No If yes, when? Target Audience* Adults Children Both Adults and Children Medical Professionals Health Agency Staff Anticipated Number of Participants Please provide day-of-event details, such as set-up time, driving/parking directions, and contact information (e.g.cell phone number) Children’s Nebraska participation is dependent on resources, scheduling and staff availability. Completing this event request form does not guarantee participation. A staff member from Children’s Nebraska Trauma Department will contact you to follow up on your submitted request.