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Brain Injury Education Request Form
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PUBLIC EDUCATION REQUEST FORM

Date requested (please include year) *

Time requested (include start and end time) *

Location & Address of event *

Contact name *

Organization *

Telephone number *

Email address *

Audience description *

Estimated number of participants *


Requested program *

Brain Care Centre Services

Concussion Management and/or ImPACT Baseline Testing

Display/Info Booth

Overview of Brain Injury (Brain Basics)

Supports/Strategies

Workplace Safety

Other


Audio/Visual equipment available *

Projector

Laptop computer

Speakers

SMART Board

N/A


Please Identify your agency's objective or outcome measure.

Are there any audience members with disabilities who require special accommodation or presentation format?