You must have JavaScript enabled to use this form. Presentation Needs Purpose of Request or Event: Participants: Court personnel Firefighters Police officers EMS Medical personnel Senior citizens General public Teachers/Counselors Students Other Grade Level: If you are requesting a presentation for students please specify the grade level of the students here. Other: If you specified other in the list above please describe who will be the participants in the presentation. Projected Number of Attendees: Presentation held in conjunction with other activities or event? Yes No If yes, specify event and other participants: Publicity/Advertising for event? Yes No If yes, please specify: Presentation Requested: Please let us know the presentation that you would like for us to present. Burn Injuries Trauma Injuries Senior Safety Fire Safety & Prevention Hazard House Trauma Burn Booth Display Trauma Burn Program Information & Referral Process Straight Talk Other If other, specify presentation: Presentation Length: 1/2 - 1 hour 1 - 2 hours Other If other, specify length: Preferred Date and Time of Presentation: Presentation Equipment Available: Requesting Group/Agency: Contact Information Contact Person: * Phone: Fax: Email: Program Location Street Address: City: ZIP Code: Other Comments: Thank you for your request! Messages generated by this form are read only on weekdays during business hours. If your message is received after hours or on a weekend, it will be processed the next business day. If you experience any issues with the submission of this form, please contact traumaburn@umich.edu. It is not possible to assure security on this system so do not send confidential information using this medium.
