You Can Help Other Parents

Nobody is prepared when a child is hurt or even killed by something that happens accidentally. Even knowing that your family avoided something serious can be shocking. Sharing your experience with others may help you cope.

Your story can also help others understand the importance of preventing injuries to children. Statistics just don’t work as well. You could be an effective advocate for new or stronger legislation in your state or nationwide. You could also be an inspiring volunteer who distributes safety devices in your community or just someone believable who talks to other parents about how to keep their kids safe.

If your family has been personally affected by an injury, OR if someone in your family has been spared from injury because of some action you took (installed a smoke alarm, used a bike helmet or a child safety seat, etc.), please fill out this both pages of this form as completely as you can.
Submitted By:
Date:
Name of child:
Child's home address:
City, State, & Zip:
Child's age:
Child's date of birth:
Child's gender:
Child's ethnic background:
Name of parent or guardian:
Address of parent or guardian:
City, State, & Zip:
Parent(s) e-mail address:
Parent(s) phone number:
Location (town and state):
When did it happen? (month and year)
Please describe what happened:
Is there a lawsuit?
Was anyone using a safety device?
If yes, what kind of device?
Did the child survive the injury?
Any permanent disabilities?
Does the child have any other type of disability?
Has the child or family been interviewed by the media?
If so, please list when and by who:
Please select anything that interests you:
Do you have any photographs you would be willing to share?