Poison Prevention Presentation Form

Educators,

Your poison prevention presentations are very important to us. Please take a few minutes to tell us about the presentations you have given. (Note that only Educators presenting in North Carolina may submit presentation information.)

We thank you for all that you do!

THE EDUCATION STAFF OF THE CAROLINAS POISON CENTER

**All text boxes, except for the telephone number, must be filled out in order to submit the form.**

Presenter's Name

Presenter's Title

Presenter's Phone Number

Presenter's Phone Number Phone Number:

Organization Name (enter No Organization, if not applicable)

County in North Carolina

Date of Presentation

	MM		DD		YYYY
Date	Date of Presentation Date Month	/	Day	/	Year