Association for Professionals in Infection Control and Epidemiology

1400 Crystal Drive, Suite 900, Arlington, VA 22202

Toolkit and Resources for APIC Members

IIPW 2018 Member Toolkit 1

Dear APIC Members:

Thank you for supporting 2018 International Infection Prevention Week. IIPW, part of the

Infection Prevention and You campaign, helps patients, families, and healthcare professionals

better understand their role in preventing infections. APIC is planning exciting activities and

creating resources around this year’s IIPW theme: Protecting Patients Everywhere.

IIPW is a time for infection preventionists (IPs) to raise awareness of the role infection

prevention plays in improving patient safety. We hope you will help to elevate the role of the IP

by joining APIC in celebrating IIPW. APIC has resources and tools to help maximize your impact

during IIPW and all year.

This document includes everything you need to advocate and promote IIPW. Additionally, the

Infection Prevention and You website has the tools and materials to give infection prevention

special recognition about why infection prevention matters. Explore these resources and

incorporate them into your IIPW celebration and activities.

To spread awareness of IIPW and provide the public visibility regarding IPs, APIC has created

materials for your facility’s public relations or communications department to use as they see fit.

Furthermore, APIC has developed resources to raise the profile of the IP and infection

prevention department.

By joining your friends, healthcare colleagues, and facilities in celebrating IIPW, you are raising

awareness of the role infection prevention plays to improve patient safety.

Thank you again for preventing infections this week and all year long!

Sincerely,

Elizabeth Garman, CAE

Vice President, Communications and Practice Resources

Association for Professionals in Infection Control and Epidemiology

www.apic.org/infectionpreventionandyou

IIPW, October 14-20, 2018

IIPW 2018 Member Toolkit 2

The 2018 theme for International Infection Prevention Week is Protecting Patients Everywhere. Patient safety is a clear priority for infection preventionists (IPs) and healthcare professionals. Celebrate the infections prevented and lives saved this year. Learn easy ways to participate in IIPW this year.

Social Media

What better way is there to spread information about germs than going viral? Follow APIC on

Facebook and Twitter and share our posts with your followers. APIC has developed tweets and

posts for you and your facilities to easily share on social media.

Twitter Chat

On Tuesday, October 16 at 12 PM ET, APIC will host a Twitter chat to discuss how healthcare

providers, patients, and others can prevent infections throughout the continuum of care.

Follow @APIC on Twitter and use the hashtag (#IIPWChat) to join.

Infographics and Posters

APIC developed a new infographic poster for IPs to share with their facilities to help educate

healthcare professionals and others on how to stop the spread of infection. Download the

Protect Your Patients infographic today. All APIC infographics are print-ready and free.

Gear Up for IIPW

Shop this exciting new collection of IIPW 2018 merchandise, perfect for inside and outside the

healthcare facility. Say thanks to the IP in your life (or treat yourself) with our exciting new

merchandise. Place your order by October 1 to ensure it arrives in time for IIPW.

Games and Activities

Are you looking for online resources to help engage people about infection prevention? APIC

has games and activities (word searches, coloring sheets, and activity pages) that are perfect all

ages and infection prevention skill levels!

Polls and Quizzes

Test your infection prevention knowledge by taking our quizzes and polls! Post your germy

results on your social media pages and challenge your networks to beat your scores!

Infection Prevention Pledges

Pledge to prevent infections and protect patients! APIC has two pledges (for healthcare

professionals and for patients and families); both are available in English and Spanish.

Infection Prevention Videos

Watch and share these infection prevention videos. You’ll see videos promoting infection

prevention best practices that will make you laugh, cry, reflect, strategize, and tap your feet!

Show these videos during staff meetings or share them on your social media channels.

Stay in the infection prevention loop: Connect with APIC on Twitter and Facebook.

Social Media Posts to Share

IIPW 2018 Member Toolkit 3

APIC has prepared sample Facebook and Twitter posts that you can use at any time leading up to or during IIPW (October 14-20, 2018). We also encourage you to create your own posts. You can also share APIC’s Facebook posts and retweet APIC’s tweets during this week. All you need to do is copy, paste, and post!

Follow @APIC on Twitter Like APIC on Facebook. Direct your followers to www.apic.org/InfectionPreventionandYou.

Facebook Posts

International Infection Prevention Week (#IIPW), October 14-20, celebrates the importance of infection prevention and patient safety. Raise your voice and spread the word that everyone plays a role in #infectionprevention. www.apic.org/InfectionPreventionandYou

Learn more on how to protect patients everywhere during International Infection Prevention Week (#IIPW) October 14-20. Follow @APIC on Facebook for the most up-to-date information: www.facebook.com/APICInfectionPreventionandYou

Join APIC for an #IIPW Twitter chat on Tuesday, October 16 at 12 PM ET to discuss the important roles that patients, families and healthcare professionals play in infection prevention and patient safety. Use the hashtag #IIPWChat to join the conversation.

According to the CDC, approximately 1 in 25 hospitalized patients will contract a healthcare-associated infection (HAI), and about 75,000 of those patients will die. Learn how to prevent infections and stay safe in healthcare settings: www.apic.org/InfectionPreventionandYou

Infection prevention is everybody’s responsibility. Each of us—patients, families, and healthcare personnel—has an important role to play in keeping patients safe from infection. Learn more during #IIPW: www.apic.org/InfectionPreventionandYou

APIC developed a new infographic poster to help educate healthcare professionals and others on how to stop the spread of infection. Download all of @APIC’s free #infectionprevention resources. http://professionals.site.apic.org/infographic/ #IIPW

Do you know how to stay safe from infections while in healthcare facilities? Be an empowered patient. Learn the #infectionprevention basics during International Infection Prevention Week, October 14-20 and use them all year long: www.apic.org/infectionpreventionbasics

APIC has polls and quizzes available to test your #infectionprevention knowledge. Challenge your friends and colleagues to a battle of the germy wits. #IIPW http://professionals.site.apic.org/get-social/polls-and-quizzes/

Clean hands stop germs! Together, we can help make it easier for patients and care givers to talk about hand hygiene and infection prevention. Download, use, share, and have fun with these during International Infection Prevention Week, October 14-20 and beyond! #IIPW www.apic.org/cleanhandsstopgerms

Do you know the ABCs of antibiotics? @APIC has infographics for both patients and healthcare professionals. Learn when it is appropriate to need/prescribe #antibiotics. www.apic.org/ABCs-of-Antibiotics #saveABX #IIPW

Do you know the value of #infectionprevention? Learn the importance of preventing these infections. https://www.youtube.com/watch?v=43WV-vYza8c&feature=youtu.be @APIC #IIPW

Social Media Posts to Share

IIPW 2018 Member Toolkit 4

Twitter Posts Please use the hashtag #IIPW in your tweets.

#Infectionprevention starts with you, but it takes a team to protect patients. Learn more with @APIC during #IIPW October 14-20 www.apic.org/InfectionPreventionandYou

International Infection Prevention Week (#IIPW), October 14-20, celebrates the importance of infection prevention and patient safety. Raise your voice and spread the word that everyone plays a role in #infectionprevention. www.apic.org/InfectionPreventionandYou

Learn more on how to protect patients everywhere during International Infection Prevention Week (#IIPW) October 14-20. Follow @APIC on Twitter and Facebook for the most up-to-date information: www.facebook.com/APICInfectionPreventionandYou

According to the CDC, approximately 1 in 25 hospitalized patients will contract a healthcare-associated infection (HAI), and about 75,000 of those patients will die. Learn how to prevent infections and stay safe in healthcare settings: www.apic.org/InfectionPreventionandYou

Show your support for #infectionprevention by participating in #IIPW this year (October 14-20)! www.apic.org/InfectionPreventionandYou

#Infectionprevention is everybody’s responsibility. Each of us—patients, families, and healthcare personnel—has an important role to play in keeping patients safe from infection. Learn more: www.apic.org/IIPW #IIPW

Keeping patients safe from infection is everyone’s responsibility. From nurses to doctors, environmental services to the OR, everyone needs to know the top ways to prevent infections. Learn how healthcare professionals can protect patients everywhere: www.apic.org/protectyourpatients #IIPW

Learn how to healthcare professionals can protect patients everywhere—in clinics, hospitals, at home, or where ever care is received. Download the free Protect Your Patients infographic poster today: www.apic.org/protectyourpatients #IIPW

What role can patients play in #infectionprevention? Learn more during #IIPW October 14-20 www.apic.org/InfectionPreventionandYou

Patients are essential members of the healthcare team. Learn more during #IIPW #infectionprevention October 14-20 www.apic.org/InfectionPreventionandYou

Healthcare Professionals: Learn the top ways to protect patients with this new infographic from @APIC: www.apic.org/protectyourpatients #IIPW

Patients: Learn #infectionprevention basics and stay infection free in healthcare settings. www.apic.org/infectionpreventionbasics #IIPW

Flex your #infectionprevention muscles with these quizzes. #IIPW http://professionals.site.apic.org/get-social/polls-and-quizzes/

Pledge your support for #infectionprevention and #patientsafety. Sign the pledge! #IIPW @APIC www.apic.org/infectionpreventionpledge

Do you know the value of #infectionprevention? Learn the importance of preventing these infections. https://www.youtube.com/watch?v=43WV-vYza8c&feature=youtu.be @APIC #IIPW

Social Media Posts to Share

IIPW 2018 Member Toolkit 5

Twitter Chat Posts Please use the following tweets to promote the Twitter chat

Join the #IIPWChat on Tuesday, October 16 at 12 PM ET to discuss #patientsafety and #infectionprevention basics. #IIPW

What can healthcare professionals, patients, and families do to prevent the spread of germs? Join the #IIPWChat with @APIC, 10/16 at 12 PM ET to learn more.

Join APIC for an #IIPW Twitter chat on Tuesday, October 16 at 12 PM ET to discuss the important roles that patients, families and healthcare professionals play in infection prevention and patient safety. Use the hashtag #IIPWChat to join the conversation.

Making #infectionprevention a top priority allows for the spread of information not germs. Join @APIC for the #IIPWChat on October 16 at 12 PM ET and have your voice heard.

Images for Tweets and Posts Please feel free to use these images with your tweets and posts.

IIPW Merchandise

IIPW 2018 Member Toolkit 6

Celebrate IIPW 2018 with new merchandise that is perfect for thanking a colleague for preventing

infection! APIC has the infection prevention gear you want for inside and outside of your

healthcare facility. Shop this exciting new collection of IIPW 2018 merchandise offered by APIC

and Jim Coleman, Ltd. Order by October 1 to ensure it arrives in time. Shop today!

Raising the Profile of the Infection Preventionist

IIPW 2018 Member Toolkit 7

While infection prevention and control (IPC) is your job as an infection preventionist (IP), many inside your facility may not be aware of how you protect not only patients, but also the facility’s reputation and financial bottom line. APIC has materials that you can use to educate others about your role and what you do. Share the following materials to help raise the profile of the IP, letting your colleagues learn the importance of the IP and IPC in healthcare. Download and share the “Who are Infection Preventionists?” infographic. Download and share the “Who are Infection Preventionists?” consumer alert. Watch and share the “Infection Preventionists Save Lives” IP recruitment video. Watch and share the “Value of Infection Prevention” video.

Public Relations Materials

IIPW 2018 Member Toolkit 8

In order to get further visibility for IIPW and infection preventionists, APIC created the following

materials for your facility’s public relations or communications department. This information will

help highlight the key points of IIPW and the infection prevention profession.

APIC has created sample newsletter copy as well as a press release. Feel free to share with

your public relations department for use in internal and external news channels.

Additionally, you can send the email on the following page to your PR department.

International Infection Prevention Week (IIPW) is October 14-20, 2018.

IIPW takes place the third week of October each year and raises awareness of the role

infection prevention plays to improve patient safety. Patient safety is a clear priority for

infection preventionists and healthcare professionals.

The theme of IIPW 2018 is Protecting Patients Everywhere. According to the Centers

for Disease Control and Prevention, approximately 1 in 25 people are diagnosed with

healthcare-associated infections each year in the United States. Not only does this cost

the healthcare system billions in excess costs, but it also results in the deaths of 75,000

patients each year.

Preventing infection is our number one goal. Whether it be in an outpatient clinic,

emergency room, or long-term care facility, we all play a role in influencing the patient’s

health.

APIC has created pre-written materials (newsletter copy, press releases, and social

media posts) for your facility to share. All you need to do is copy, paste, and post!

On Tuesday, October 16 at 12 PM ET, APIC will host a Twitter chat to discuss how

healthcare providers, patients, and others can prevent infections and therefore protect

patients. Follow @APIC on Twitter and use the hashtag (#IIPWChat) to join. We

encourage your facility to join APIC and other patient safety leaders for an important

dialogue. If you would like to participate, message @APIC for an advance list of the

questions.

Draft Email to PR Department

IIPW 2018 Member Toolkit 9

Dear [Staff Member, PR Department],

International Infection Prevention Week (IIPW) is October 14-20, 2018.

IIPW takes place every year during the third week of October to raise awareness of the critical

role infection prevention plays in improving patient safety. Organized by the Association for

Professionals in Infection Control and Epidemiology (APIC), this year’s theme is Protecting

Patients Everywhere.

As an infection preventionist at [Name of Hospital or Facility], I’d like to ask you to join us in

encouraging everybody—healthcare personnel, patients, and families—to do their part to

protect against healthcare-associated infections.

Here’s how you can help our facility celebrate IIPW:

• Highlight IIPW in the [Facility Name/ Newsletter Title] newsletter

• Browse “Consumer Alerts” for pre-written infection prevention articles that can be

repurposed and distributed to staff and the public throughout the year

• Promote IIPW on social media and participate in the IIPW Twitter Chat on Tuesday,

October 16 at 12 PM ET (see attached for pre-written posts)

• Send out the IIPW press release to local media, adapting it to highlight the success

this institution has had in preventing infections

• [Mention any planned events here – and invite them to attend, take photos, and

include a write-up in the facility’s newsletter or magazine]

Sample copy for newsletter articles, social media posts, and press releases are included in the

IIPW Toolkit and on the APIC website.

Thank you for supporting patient safety and this year’s IIPW.

Best,

[Name, Title]

Newsletter Copy

IIPW 2018 Member Toolkit 10

International Infection Prevention Week is October 14-20

Organized by APIC, this year International Infection Prevention Week (IIPW) will focus on

protecting patients everywhere. Visit the IIPW website for free patient safety infographics, social

media posts, and more. Learn more.

Join APIC’s patient safety Twitter chat on October 16

Join @APIC for a Twitter chat on October 16 at 12 PM ET to discuss the important roles that

patients, families, and healthcare professionals play in infection prevention and patient safety.

Use the hashtag #IIPWChat to join the conversation. Learn more.

International Infection Prevention Week is October 14-20

This year, International Infection Prevention Week (IIPW) is raising awareness about the

important role we all play in preventing the spread of infection and promoting patient safety.

Join us in thanking our Infection Prevention Team at [Facility Name] for all they do to keep

patients safe by protecting them from infection. Infection preventionists (IPs) are our facility’s

infection detectives, finding germs and ensuring healthcare personnel are doing their part to

improve patient safety and care.

Let us all take the first step in helping IPs stop the spread of germs by practicing proper hand

hygiene. After all: infection prevention is everybody’s business! Learn more.

The IIPW 2018 theme is protecting patients everywhere

The theme for this year’s observance of International Infection Prevention Week, October 14-20,

is Protecting Patients Everywhere. The Association for Professionals in Infection Control and

Epidemiology (APIC) spearheads the commemoration of IIPW each year and has developed a

new infographic to help educate healthcare professionals and others on how to stop the spread

of infection. Download the free Protect Your Patients infographic today.

International Infection Prevention Week is October 14-20

This year, International Infection Prevention Week (IIPW) is raising awareness of the important

role we all play in preventing the spread of infection. Whether you are in a healthcare facility or

in the community, there are steps that healthcare professionals, patients and families can take

to stay safe from infection.

Become part of the infection prevention team by:

• Washing your hands and asking healthcare workers and visitors to do the same

• Sneezing and coughing into your elbow, not your hand

• Taking medications as directed

To learn more, visit the Association for Professionals in Infection Control and Epidemiology’s

(APIC), website.

Newsletter Copy

IIPW 2018 Member Toolkit 11

[NAME OF ORGANIZATION OR LOCAL APIC CHAPTER] partners with APIC to

celebrate International Infection Prevention Week

In recognition of the important role consumers and healthcare providers both play in infection

prevention, [NAME OF ORGANIZATION] has partnered with The Association for Professionals

in Infection Control and Epidemiology (APIC) to promote International Infection Prevention

Week (IIPW), October 14-20.

To celebrate IIPW and this year’s theme of Protecting Patients Everywhere, APIC has

expanded the resources for both patients and healthcare professionals found on the Infection

Prevention and You website (www.apic.org/infectionpreventionandyou). APIC has developed a

new infographic to help remind healthcare professionals how to stop the spread of infection.

Download the free Protect Your Patients infographic today.

On Tuesday, October 16 at 12 PM ET, APIC will host a Twitter chat, which will to discuss

protecting patients everywhere, and how everyone can work together to defend our patients,

friends, and family from infection. To participate, follow the hashtag #IIPWChat.

[NAME OF ORGANIZATION]’s members are encouraged to visit the Infection Prevention and

You website, and download and share the free infographics. Additionally, APIC has developed

pre-written social media posts.

Established in 1986, IIPW is celebrated the third week of October. APIC spearheads the annual

effort to highlight the importance of infection prevention among healthcare professionals,

administrators, legislators, and consumers. It is now formally recognized in many areas around

the world including the U.S., Australia, the United Kingdom, the Middle East, and Asia. As IIPW

expands, more patients benefit from safer healthcare practices and reduced threat of

healthcare-associated infections. Learn more about IIPW on Facebook and Twitter (#IIPW).

# # #

Press Release Copy

IIPW 2018 Member Toolkit 12

Contact: [INSERT LOCAL CONTACT]

[INSERT PHONE NUMBER]

[INSERT EMAIL ADDRESS]

[INSERT LOCAL APIC CHAPTER OR ORGANIZATION NAME] supports International

Infection Prevention Week

[INSERT CITY], October [INSERT DATE], 2018 – To highlight the importance of infection

prevention and raise awareness of everyone’s role in protecting the public, [NAME OF

ORGANIZATION OR LOCAL APIC CHAPTER] is supporting International Infection Prevention

Week (IIPW), October 14-20.

“We want to engage our community around this important topic and therefore will be hosting

several events to outline the ways in which patients, families, and healthcare providers can all

work together to keep patients safe,” said [ORGANIZATIONAL SPOKESPERSON]. “It takes a

team to truly protect patients everywhere, and we need everyone’s help.”

The 2018 IIPW theme is Protecting Patients Everywhere. Healthcare professionals from all

settings and levels play an important role in protecting patients. APIC has provided free

downloadable resources and activities for patients and families, as well as, fact sheets on

infection prevention basics, settings of care, and more. The Infection Prevention and You

website is accessible here: www.apic.org/infectionpreventionandyou.

New this year, APIC has developed a new infographic to help remind healthcare professionals

and others how to stop the spread of infection. Download the free Protect Your Patients

infographic today.

“Keeping patients safe from infection is everyone’s responsibility. From nurses to doctors,

environmental services to the OR, everyone needs to know the top ways to prevent infections,”

said [ORGANIZATIONAL SPOKESPERSON].

Local IIPW activities that are planned include: [INSERT SUMMARY OF ACTIVITIES AND

DETAILS].

Established in 1986, IIPW is celebrated the third week of October. APIC spearheads the annual

effort to highlight the importance of infection prevention among healthcare professionals,

administrators, legislators, and consumers. It is now formally recognized in many areas around

the world including the U.S., Australia, the United Kingdom, the Middle East, and Asia. As IIPW

expands, more patients benefit from safer healthcare practices and reduced threat of

healthcare-associated infections.

Learn more about IIPW on Facebook and Twitter (#IIPW).

# # #

[INSERT LOCAL APIC CHAPTER LOGO

OR HEALTHCARE FACILITY LOGO HERE]

IIPW Ideas

IIPW 2018 Member Toolkit 13

Activities for Healthcare Professionals and Facilities

Here are ideas for events or activities to help raise awareness about the importance of infection

prevention in your healthcare facility.

• Use IIPW logos and other sample materials to create signs, posters, banners, screen

savers, and announcements for your facility.

• Print out the Infection Prevention and You infographics, brochures, flyers, and posters to

educate patients about preventing infection.

• Draft a letter to your healthcare administration that includes details on IIPW and how

infection prevention contributes to patient safety. (page 9)

• Insert IIPW announcements in employee newsletters. (pages 10-11)

• Add an IIPW message to your email signature line.

• Use fluorescent hand lotion to educate employees about hand hygiene.

• Order IIPW branded merchandise for booths, displays, or prizes.

• Create IIPW tray liners for cafeteria food trays.

• Share these infection prevention quizzes; offer prizes, such as IIPW stickers or other

themed giveaways.

• Take a “what’s wrong?” approach. Use photos or posters for staff to identify infection

prevention mistakes.

• Show infection prevention videos during staff meetings.

• Pledge to take action and encourage others to prevent infections and protect patients.

• Offer employee flu shots during IIPW.

• Promote safety nurses during IIPW – Have them staff booths/events, give flu shots;

display their photos, feature their bios in the employee newsletter

Activities for Community Engagement

Here are ideas for events or activities to help raise awareness about the importance of infection

prevention in your community.

• With your local APIC chapter, reach out to your local health department, hospitals, and

schools to organize a joint campaign to promote infection prevention to the public.

• Pass out hand sanitizers and literature about infection prevention to community

members at bus/metro stops, grocery stores, or any other busy public areas.

• Organize a hand washing and “cover your cough” demonstration for students at local

schools.

• Plan a flu vaccine clinic for the public and pass out literature on why infection prevention

is important.

• Like the APIC Facebook and Twitter pages and drive your followers to it to engage them

in conversations about the importance of infection prevention.

• Use the Advocacy Toolkit to help guide your outreach and plan a visit to your state

legislature.

• Contact your legislators to advocate on behalf of infection prevention through the

APIC legislation page.

About

IIPW 2018 Member Toolkit 14

IIPW takes place the third week of October each year and raises awareness of the role

infection prevention plays to improve patient safety.

Association for Professionals in Infection Control and Epidemiology

APIC’s mission is to create a safer world through prevention of infection. The association’s more

than 15,000 members direct infection prevention programs that save lives and improve the

bottom line for hospitals and other healthcare facilities. APIC advances its mission through

patient safety, implementation science, competencies and certification, advocacy, and data

standardization. Visit APIC online at apic.org. Follow APIC on Twitter: twitter.com/apic and

Facebook: facebook.com/APICInfectionPreventionandYou. For information on what patients

and families can do, visit APIC’s Infection Prevention and You website at

http://www.apic.org/InfectionPreventionandYou.

Infection Prevention and You

Infection Prevention and You is APIC’s multiyear awareness campaign that features resources

for both consumers and healthcare professionals. Materials are designed to clearly and simply

convey important infection prevention information. Infection Prevention and You has print-ready

materials for hospitals, home care, long-term care, and outpatient care settings to explain the

role infection preventionists play in patient safety and educate the consumer about how to stay

infection free while receiving care.

History of International Infection Prevention Week

IIPW, part of the Infection Prevention and You campaign, helps patients, families, and

healthcare professionals better understand their role in preventing infections. Established in

1986 by President Ronald Reagan, APIC has spearheaded the annual effort to highlight the

importance of infection prevention among healthcare professionals, administrators, legislators,

and consumers. Over the years, this week of recognition has vastly expanded to every corner of

the globe, including Australia, the United Kingdom, the Middle East, and Southeast Asia. As the

reach of IIPW widens, more patients benefit from safer healthcare practices and reduced threat

of healthcare-associated infections.

Protecting Patients Everywhere

According to the Centers for Disease Control and Prevention, approximately 1 in 25 hospitalized

patients get healthcare-associated infections each year in the United States. Not only does this

cost the healthcare system billions in excess costs, but it also results in the deaths of 75,000

patients each year.

Preventing infection is our number one goal, whether care is delivered in a hospital, an

outpatient clinic, or long-term care facility. Patients, families, and healthcare personnel all play

an important role in influencing a patient’s health.

APIC Photo Release Form

IIPW 2018 Member Toolkit 15

I, _________________________________________________ (please print), whose address is

____________________________________________________________________________________

___________________________________________________________________________________,

hereby grant to the Association for Professionals in Infection Control and Epidemiology (APIC), as well as

to their respective representatives, chapters, agents, members, and employees, the right to take

photographs of me and my property the right to use such photographs, royalty free, with or without my

name, for any lawful purpose, including but not limited to, for the purposes of publication, illustration,

promotion, advertising and internet content, in any form or medium, in print or electronically. I further

acknowledge and agree that APIC shall own the copyright in the aforementioned photographs.

I have read, understand and agree to the above release.

Signature: ______________________________________

Date: ______________________________________

Signature of parent or guardian if under the age of 18: _____________________________________________

Name of parent or guardian if under the age of 18: _______________________________________________