Shock Trauma Center: Request Form for Community-Based Prevention Programs

Shock Trauma Center:

Request Form for Community-Based Prevention Programs

Thank you for your interest in our offerings from the Shock Trauma Injury Prevention Program! Our goal is to provide engaging and research-validated injury prevention programming for groups of all ages. We collaborate with the ThinkFirst® National Injury Prevention Foundation and the experts at Shock Trauma for a shared mission of preventing brain, spinal cord, and other traumatic injuries through education and advocacy.

Please complete the form below and we will return your request as soon as possible.

Contact Information

First and last name*

Email address*

Contact number:*

Phone

Person in charge on day of visit (if different)*

Contact phone number on day of program (if different)*

Phone

Organization Information

Name of group, facility, or organization:

Type of group or organization*

Select all that apply.

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Street address of group, facility, or organization:*

Zip code of group, facility, or organization:*

Anticipated number of participants*

Date/Time Information

Desired date:*

If possible, please provide at least 3+ options, as well as any additional information that may assist in accommodating your request (i.e. "anything in June" or "nothing on Fridays").

Requested start time*

Requested end time*

Desired Program

Teen Concussion/Head Injury Prevention Class (by ThinkFirst®)

Interactive class covering topics related to Traumatic Brain Injury, including basic neurophysiology, helmet use, concussion protocols, CTE, return to sport, etc.

Trauma Prevention Teen Talk (by ThinkFirst®)

Interactive class in which teens come to understand the consequences of making unsafe choices; covers a wide range of topics on injury prevention including driver safety, water safety/diving education, sports and recreation, helmets, violence, substance use, fireworks, pedestrian safety, bike safety, etc.

Teen Driver Safety Workshop (by ThinkFirst®)

Interactive class focused exclusively on driving/traffic safety. Teens come to understand the consequences of drunk/impaired driving, speeding, distracted driving, etc.

Older Driver Safety Workshop (by ThinkFirst®)

Educational class that that addresses the changes in driving as we age and how to stay safe on the road while preserving independence.

Falls Prevention Class (by ThinkFirst®)

Educational class intended for older adults and caregivers/families of older adults covering topics such as medication management, home modifications, exercises, and tips for taking to your doctor.

STC Drinking Driver Monitoring Program (DDMP)

Educational class is intended for individuals who have operated a motor vehicle while intoxicated or impaired. The majority of individuals are ordered to attend DDMP by the courts or by the medical advisory Board of the Maryland Motor Vehicle Administration. Hosted on-site at Shock Trauma regularly on the second Wednesday of each month. Fee associated and registration required.

If none of the above, are you requesting our presence at a tabling event (such as an expo, trade show, fair, festival, etc.) rather than a sit-down program/class?

Does your group have any special considerations we should prepare for or anticipate?*

I.e.: disability accommodations, specific topics to cover or avoid, any sensitive or triggering topics, students with special needs/circumstances

Do you have anything additional to note?*

How did you hear about us?*

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