Coast-2-Coast Toolkit Request Form

Your Information

* Name:

Institution:

* Address 1:

Address 2:

* City:

* State/Province:

* ZIP/Postal Code:

* Country:

* Phone:

* Email:

*Are you a WDS Member?
Yes, I am a WDS Member or my WDS Membership is pending
Note: Coast-to-Coast Toolkits are available to WDS Members only.

Event Information

* Outreach Activity Planned (please describe):

* Location of Event:

* Date of Event:

* Time of Event:

* Expected Number of Participants:

* Age Range of Participants:

Shipping Information

Address for shipping (if different from above):

Is this a residential address?
Yes
No

Shipping Address 1:

Shipping Address 2:

* Shipping City:

* Shipping State/Province:

* Shipping ZIP/Postal Code:

* Shipping Country:

* Date you would like items to arrive:

Additional comments:

Material Request

Please check all items you would like shipped to you.

Are screenings being performed at this event?

Yes

Large Play Safe in the Sun Supply Crate *(Crate must be returned within 2 weeks of event completion)

2 Small Collapsible Baskets
1 Medium Collapsible Baskets
1 Large Collapsible Baskets
2 Long Clip Boards
2 Short Clip Boards
Hand Held Mirrors
1 Boxes of Latex Free Gloves
1 Large bag of Alcohol wipes
1 Navy Table Cloth

Screening Only Kit *(Kit does not need to be returned to WDS)

1 Boxes of Latex Free Gloves
1 Bag of Alcohol wipes
Purrell

Screening Forms
Please indicate quantity for each.

AAD Spotme® Skin Screening Registration and Report Forms (Packs of 50)
AAD Spanish Spotme® Skin Screening Registration and Report Forms (Packs of 10)

Samples & Educational Materials
Please indicate quantity for each.

La Roche-Posay Sunscreen Samples
WDS UV Detecting Bracelets*
ABCDE's of Melanoma Flyer
Are YOU Playing Sun Safe Flyer
Kids Sun Safety Flyer
WDS Play Safe in the Sun Card - Spanish

*Note that these items are an additional cost to the WDS, please submit your request based on your expected event attendance

WDS Materials
Please indicate quantity for each.

Membership Applications
Membership Brochures
Awards Brochures
Service Brochures
Journal Information Cards

**All items unused after your event should be shipped back to the WDS National Office, shipping labels will be pre-paid and included for your convenience
***WDS strives to meet each member's toolkit request and requirements. However, toolkit materials are dependent upon inventory and distributed on a first come, first served basis

Please email wds@womensderm.org if you would like to request the WDS registered logo for use, or have any other special requests.

Thank you for hosting a Coast-2-Coast event! We want to showcase your volunteerism on our website and in our newsletter. Please send recaps and any photos to wds@womensderm.org.