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Online Order Form
(Materials will be shipped 2-3 weeks prior to event date)

Poison Prevention Educator Information:
Please check that all information is correct.  If changes need to be made, please go to My Profile  

Current Information: Ship To: (if different)
Label

Name

Organization

Address

City
 State
  		Zip


We Can Not ship to a P.O. box. Please list a regular address.
* Complete one order form for each event or distribution

Event Details 
Please fill in required information marked with the asterisk (*)

Event Name * 

Event Type * 
Event Host (i.e. Babies R Us)  * 
Target Group * 
Event City * 
Event County * 
Event Zip * 
Audience Ethnicity * 


Event Date *
 Total Hrs of event

Number of participants * 
Satellite coordinator you are working with, if none choose IPC *
Optional comments about this event (or order form)
Materials Available for Request (Free)
Place a check mark by the material(s) needed.  Quantities will be determined by the IPC.
 Material Description English Spanish
1. Protect your Family from Poison Brochure
2. Your Guide to Medicine Safety Brochure
3. Your Guide to Plant Safety Brochure
4. Carbon Monoxide Fact Card
5. First Aid Fact Card
6. Lead Fact Card
7. Mercury Fact Card
8. Older Adult Fact Card
9. Refrigerator Magnets
10. Telephone Stickers
11. Poster (one side in English/other side Spanish)




© 2007 Illinois Poison Center, a program of the Metropolitan Chicago Healthcare Council