Dell Children’s Medical Center of Central Texas
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Central Texas Injury Prevention Speakers Bureau

Fields outlined in orange are required.

Contact Name/Administrative Representative
Contact Name:
Name of Organization, School, Association:
Mailing Address:
State:     Zip:
Contact Phone:  -   -   EXT 
Alternate Phone:  -   -   EXT 
Contact Fax:  -   - 
Contact Email:
Agency Website:
Date/Start Time/Length Desired for Your Meeting
Start Time:    
Alternate Date:    
Alternate Start Time:    
Length of Presentation:
Event Location
Room Number / Building:
Street Address:
State:     Zip:
Topic Desired for your Meeting
Target Audience / Age Group
Audience Information
Expected Size:   (e.g. 20 parents, 50 community members, etc.)
Composition:  (e.g. PTA, school, church group, etc )
Language Desired:  English  Spanish
Special Requests/Notes: