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.**

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Presenter's Name

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Presenter's Title

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Presenter's Phone Number

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Organization Name (enter No Organization, if not applicable)

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Date of Presentation

Date

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Number of CHILDREN reached

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Number of ADULTS reached

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