2023 National Injury Prevention Day Signature Request

Sign-On

National Injury Prevention Day (November 18th) is designed to raise awareness about the burden of injury and violence and the need for change. It is dedicated to educating and empowering communities to make a difference in work toward reducing injuries and deaths. In partnership with a number of national partnership organizations, the Injury-Free Coalition for Kids asks that you express your organization’s commitment to join forces to support and promote National Injury Prevention Day on November 18th by shining a green light and promoting the day among your membership, constituencies and communities. Also, please wear green that day to send a unified message that it's time for change. Thanks again for your commitment to preventing injuries and acts of violence.

Question Title

* 1. Please provide your name, title, and organization you are representing.

Name

Title

Organization

Question Title

* 2. Contact Information

Address *

Address 2

City/Town *

State/Province *

ZIP/Postal Code *

Email Address *

Phone Number *

Question Title

* 3. We encourage you to join us in taking the necessary steps to minimize injuries and violence in all communities. Please check this box to sign onto this document.

I agree to sign on

Question Title

* 4. Please check this box authorizing your ability to sign this document on behalf of your organization.

I am authorized

Question Title

* 5. Please attached a link or photo below of your organization’s logo

PDF, DOC, DOCX, PNG, JPG, JPEG, GIF file types only.

Choose File