Online Materials and Training Order Form
1

Contact Information

Contact Person:
Organization:
Address:
City:
State:
Zip:
Phone:
Fax:
Email:
2

What are these materials to be used for?

Request a Presentation
3
I would like to request a presentation/ training session:]
4
If yes, please indicate requested date:
5
Additional comments:

Materials Request
6

Safe Health Flyer
Please fill-in the desired quantity for each language.
Click to view
English:
Spanish:
Laotian:
Cambodian:
7

Safe Health Poster
Please fill-in the desired quantity for each language.
Click to view
English:
Spanish:
Vietnamese:
Laotian:
Cambodian:
8

Protect the Health of Your Family
Please fill-in the desired quantity.  Click to view
Spanish only:
9

Prevent a Family Tragedy
Please fill-in the desired quantity.  Click to view
Spanish flyer version:
Spanish poster version:
10

A Healthy Family is a Happy Family
Please fill-in the desired quantity.
Vietnamese only:

By clicking "Submit" you can send this form electronically. As an alternative you can also print this form and mail or fax your request to the following:

Safe Healthcare Project 
1725 West 17th Street Room 120M
Santa Ana, CA 92706
(714) 834-8775
(714) 834-8051 Fax