SERTAC Fall Prevention Toolkit/Magnet Request Form
If you are an organization and would like to receive hard copies of the falls prevention toolkit and/or fall prevention/home safety magnets to distribute to your constituents, please fill out the information below. We will follow up with you on pick up instructions once your request has been received. Please note: Request must be for a minimum of 50 toolkits/magnets and in increments of 50 and not to exceed 200. We may contact you in the future for feedback on how you utilized and distributed these toolkits.
Organization Name
*
Organization Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Full Name
*
First Name
Last Name
Phone Number
*
E-mail
*
example@example.com
Population your organization serves
*
How did you learn about the toolkits/magnets?
*
How do you intend to utilize/distribute the toolkits/magnets?
*
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Fall Prevention Toolkits
Minimum of 50 and maximum of 200 (please order in increments of 50)
$
Free
Quantity
Exercise magnets
Minimum of 50 and maximum of 200 (please order in increments of 50)
$
Free
Quantity
Submit
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