Public Education Materials Order Form

Serving Nebraska, Idaho, Wyoming, American Samoa, and Federated States of Micronesia

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1. Amount requested for each item:

Coloring Books

Magnets

Brochures

Telephone Stickers

Spanish Brochures

Spanish Telephone Stickers

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2. Would you like a Teachers Packet for Preschool - Grade 2? (1 packet is provided for each order)

Yes

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3. How many poison prevention presentations will be done?

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4. Which DVD(s) would you like mailed in your order?

Videos will be viewed online at www.nebraskapoison.com

DVD (Preschool - Grade 2: Pinky) Please mail DVD back in bubble envelope provided. You will need to provide postage.

DVD (Teen - Adult: Prescription Drug Abuse) Please mail DVD back in bubble envelope provided. You will need to provide postage.

DVD (Teen - Adult: Poison Prevention) Please mail DVD back in bubble envelope provided. You will need to provide postage.

Not interested at this time

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5. Which of the following best describes your professional affiliation?

Medical Facility

Daycare/Preschool

Elementary School

Middle School

High School

Parent/Guardian

Other Organization

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6. What is your age?

Under 18

18-24

25-34

35-44

45-54

55-64

65+

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7. Please provide your contact information.

Name

Name of School/Company

Mailing Address (street address if possible)

City/Town

State/Province

ZIP/Postal Code

Email Address

Phone Number

Thank you for taking time to complete your order!