<Coalition Form>

Washtenaw County Safe Sleep Coalition

Campaign Recruitment Survey

Soon we will be kicking off a public awareness/education

campaign throughout the County.

We will need partners in a Safe Sleep coalition to help strategize how best to launch an effective campaign, as well as to help implement the plan through various important tasks. We will contact you soon to arrange for our first meeting.

Please fill out the form below and indicate your preferences.

Name_______________________________________________________________________

Place of Employment (if you will be representing an agency or business)

____________________________________________________________________________

Position_____________________________________________________________________

Address_____________________________________________________________________
City, State, Zip ____________________________________________________________________________

Phone_______________________________________________________________________

E-Mail _____________________________________________________________________________

Yes, I am interested in becoming part of the Safe Sleep Coalition

I would be able to help in the following ways (check all that apply):

___Help with the planning of the public awareness campaign.

___Recruit others from my organization to participate in the coalition.

___Coordinate a training at my organization/agency/department/practice.

___Speak on the topic at a training at my organization, agency, department,

or practice.

___Provide outreach to community groups through presentations.

___Share information with clients/patients.

___Place an article in my agency/department newsletter.

___Post information at my organization/agency/department/practice.

___Help distribute information to other community sites including clinics, doctors’

offices, and libraries.

___Review current policies and practices within my organization to assure

consistency with a safe sleep message.

___Provide financial or in-kind support.

___Sorry, I’m not able to participate at this time, but please keep me on your

mailing list.

For more information please contact us at:

WACC, 3075 W. Clark Rd., Suite 110, Ypsilanti, MI 48197

(734) 434-4215

marcia@washtenawchildren.org