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Educational Materials Request Form

To ensure you receive your materials in a timely manner, please make your request 30 days before your scheduled event.
NOTE: If you are requesting a Komen representative and/or speaker in addition to educational materials, please use the Health Fairs | Speaker Request Form only.

 

Provide your contact information.

  Contact Information

*

Name:

 

 

   

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City/State/ZIP:

 

    

 

 

 


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Question - Required - Date Materials Needed




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  If you answered NO to the previous question, where would you like the materials shipped?

 

Name:

 

 

   

 

 

 

City/State/ZIP:

 

    

 

If you respond and have not already registered, you will receive periodic updates and communications from Susan G. Komen® Northeast Ohio.


 

What educational materials are you requesting?

Indicate the number of each requested, up to a total of 100 items.

 

Breast Self-Awareness Card

 


 


 


 

General Breast Health Information Brochure

 


 


 

Men Can Get Breast Cancer, Too

 


 


 

Young Women Brochure

 


 


 

Mammography Card

 


 


   Please leave this field empty