Resource Guide Application

Resource and Referral Guide

Application for Membership

* Indicates a required field

* Click here to download and print a hard copy of this application.

* Name of Organization:

* Address:

* City:

* State:

* Zip:

* Phone Number: (area code + number)

* Fax Number: (area code + number)

* Website (if applicable):

* Name and title of Contact Person:

* E-mail Address

Tell us about your organization:

1- Is your organization a for-profit or a non-profit organization?
	For Profit, provides a product		For Profit, provides a service		Non Profit		Government agency

2- Is your organization a member of the California Chapter 4, American Academy of Pediatrics’ Injury Prevention Collaborative?
	Yes		No

3- What is your target population? (Check all that applies)
	0 - 5 years		6 - 18 Years		Parents

4- What county/counties does your organization serve? (Check all that applies)
	Orange		Riverside		San Diego		Los Angeles

5- What demographic areas in Orange County does your organization serve? (Check all that apply)
	North County		Central County		South County

6- What language capabilities does your organization have? (Check all that apply)
	English		Spanish		Vietnamese	Other, Please list:

7- Does your organization address intentional or unintentional injuries?
	Intentional		Unintentional		Both

8- What Unintentional injury prevention areas does your organization provide services? (Please check all that apply)
	Burns	Falls	Residential Fire
	Child passenger Safety	Helmet Safety	Sports Injuries
	Daycare/Playground Safety	Home Safety	Unintentional Firearm
	Drowning	Pedestrian Safety	Other:
	Environmental Safety	Poison

9- What Intentional injury prevention areas does your organization provide services? (Check all that apply)
	Child Abuse	Domestic Violence	Firearms
	Other:

10- Please provide a description of the type(s) of injury prevention services your organization provides pertaining to the injury area in questions 8 or 9.
Educational
Materials
Training (ie: hands on, classroom training)
Direct Services

11- Please list any certifications your organization or employees have if it pertains to the injury area in questions 8 or 9.

12- Does your program follow the American Academy of Pediatrics’ Policies? (Policy Statements regarding intentional and unintentional injuries can be viewed at www.aap.org)

Yes

Other

If other, please explain

13- Would you like to nominate an organization not currently a member of the Injury Prevention Collaborative or SAFE KIDS? If Yes, please provide name, phone number of organization and contact name
	Yes

14- Please provide a brief (120 word maximum) description of your program (s). If you represent more than one injury prevention area, please write a description of each program, and include the contact name for each
(if different from contact name at the top of the application).


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If you have any questions, please call The California Chapter 4,
American Academy of Pediatrics Injury Prevention Program at (714) 971-0695.