Injury Prevention Day at the Capitol - Program Display Submission Form
RequiredRequired Question(s)
Injury Prevention Day at the Capitol will be held on Wednesday, February 13, 2019 from 1:00-4:00pm, following a luncheon hosted by the Injury Prevention Subcommittee at 11:00am at The Depot. 

We will have tables set up at both places, in hopes of showcasing the injury prevention efforts across the state of Georgia.

If you have an organization or program you would like to have on display,
please fill out the form below by Friday, January 4, 2019.

Further details will be provided to those who have submitted a program by Friday, January 11, 2019.

One (1) 6-foot table and two (2) chairs will be provided.

If you have any additional questions, please contact Lori Mabry via email at
Required 1.
Please enter your preferred contact information indicated below.

First Name:
Last Name:
Job Title:
Company Name:
Work Phone:
Email Address:
Address 1:
Address 2:
Postal Code:

Required 2.
Name of Injury Prevention Program(s)

350 characters left.
Required 3.
Program Targeted Mechanism(s) of Injury

50 characters left.
Required 4.
Briefly Describe Program(s), Area of Reach, Targeted Audience, etc.

350 characters left.
Required 5.
Are you interested in sharing a table with a strategic partner?

If yes, please list partners. (If known)


350 characters left.
Display Needs (Power, Additional Space, etc.)

350 characters left.