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Request a Speaker or Workshop
Requestor Information
First Name
*
Last Name
*
Title
Street Address
*
Town
*
Zip Code
*
County
*
Email Address
*
Group/Facility
Phone
*
Workshops
*
Helmet/Wheeled Sport Safety
Concussion in the Classroom
Introduction to Brain Injury
Adjustment to Brain Injury
Brain Injury in Students
Concussion in Youth Sports
Substance Abuse & Brain Injury
Advocacy & Appealing to NJ Elected Officials
Heads Up! Seniors
Distracted Driving
Sharing the Road
Pedestrian Safety
Teen Safe Driving
Domestic Violence & Brain Injury
Return to Work
Target Audience
(check all that apply)
*
Professionals in the field of Brain Injury
School Professionals
Professional (not brain injury specific)
People with Brain Injury
Family Members
Elementary School Students
Middle School Students
Other
High School Students
High School Students
Estimated Number of Attendees
(minimum of 25 or more attendees)
*
25-30
31-35
35+
Reason for Workshop:
0/255 characters
Prefered Date(s): List top 3 preferences for dates and time for the presentation
*
Date
Start Time
End Time
Total Time
1
Date
Start Time
End Time
Total Time
2
Date
Start Time
End Time
Total Time
3
Date
Start Time
End Time
Total Time
Please let us know if you have any additional needs regarding your requested workshop .