Publication Request Form

The Office of Child Abuse Prevention would like to share our new education and awareness materials regarding the Safely Surrender Baby program and Shaken Baby Syndrome/Abusive Head Trauma information. If you would like to request copies, please answer the questions below. Due to budget limitations, we may not be able to offer supplemental orders.

Question Title

* 1. Contact/Shipping Information

Name

Company

Address

Address 2

City/Town

State/Province

ZIP/Postal Code

Email Address *

Phone Number

Question Title

* 2. From the list of brochures below, list the quantity you would like to receive.

Pub 271 - English

Pub 271 - Spanish

Pub 400 - English

Pub 400 - Spanish

Pub 400 C1 - English

Pub 400 C1 - Spanish

Question Title

* 3. From the list of posters below, list the quantity you would like to receive.

Pub 273 A1 English (size 10x12)

Pub 273 A1 Spanish (size 10x12)

Pub 400 C1 English (size 10x12)

Question Title

* 1. Contact/Shipping Information

Question Title

* 2. From the list of brochures below, list the quantity you would like to receive.

Question Title

* 3. From the list of posters below, list the quantity you would like to receive.

Question Title

* 4. Please describe how you will disseminate the materials.