Date requested (please include year) *
Time requested (include start and end time) *
Location & Address of event *
Contact name *
Telephone number *
Email address *
Audience description *
Estimated number of participants *
Brain Care Centre Services
Concussion Management and/or ImPACT Baseline Testing
Overview of Brain Injury (Brain Basics)
Please Identify your agency's objective or outcome measure.
Are there any audience members with disabilities who require special accommodation or presentation format?