Buckle Up Virginia! Materials Request Form

The Division of Injury and Violence Prevention has the following occupant protection educational resources available free of charge for Virginia residents only. Please allow 2-3 weeks for delivery.

For additional injury and violence prevention resources visit www.vahealth.org/civp.

1. Requester's Information

Requester's Information Attention
Organization Name
Shipping Address (No PO Box)
City
State
Zip
Phone Number

2. E-Mail Address

E-Mail Address

3. Record the quantity desired for each item in the fields below.

Record the quantity desired for each item in the fields below. Buckle Up Virginia Brochure-ENGLISH
Buckle Up Virginia Brochure-SPANISH
Buckle Up Virginia Poster-Double sided-ENGLISH/SPANISH
Buckle Up Virginia Growth Chart-Double sided English and Spanish
Four Steps for Kids Poster-ENGLISH
Seat Belts Saves Lives Brochure-ENGLISH
Seat Belts Saves Lives Brochure-SPANISH
Pregnant Women and Seat Belts Brochure-ENGLISH
Pregnant Women and Seat Belts brochure - Spanish
Be Safe, Be Smart Buckle Up Activity Book-ENGLISH
Child Passenger Safety Checklist Form (For Safety Seat Inspection Events Only) Indicate # of Pads Requested (50 forms per pad)
Safety Seat Installation DVD ENGLISH/SPANISH

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