IT COSTS LESS TO PREVENT A POISON ACCIDENT THAN IT DOES TO TREAT ONE!
West Virginia Poison Center
SHIPPING INFORMATION (type or print legibly, include zip code):

Name: _____________________________
Address:____________________________
City________________________________
State_____WV_____        Zip ___________
Telephone number_____________________
Email address________________________
Materials needed by:___________________

 Material Order Sheet
 
Item
Quantity
Total
Mr. Yuk stickers (#@.10 each) $
WVPC Phone stickers (# @ .10 each) $
Your Poison Center Help Brochure... (# @.15 each) $
What About Plants Can be duplicated $
Poisonous Snakes Can be duplicated $
Poison Checklist Can be duplicated $
Poison- Older (# @.15 each) $
Teachers Packet (only one per person) $


Audio - Visual Materials Order Sheet

Reserve Dates
First Choice_________; Second Choice__________; Third Choice__________


Title
 Please check 
video request
Pretty Petals
Wash Your Hands
Fatal Attraction
Child Resistant Packaging

 If you are borrowing audio-visual materials, then you are required to agree to the terms in our loan policy.

  • A/V materials must be reserved at least two weeks in advance.
  • All materials are available for a 7 day loan only. Please return the A/V materials via certified mail.
  • The borrower accepts full responsibility for lost or damaged A/V materials
  • Please be considerate of others borrowing A/V materials and return the materials by the specified return date.
  • The borrower must notify the WVPC of any defects in the A/V materials upon being returned.
I accept full responsibility for lost or damaged materials:
Signature:_________________________________
NOTE: All orders must be prepaid.  Sorry, but only West Virginia residents may receive items. Send a print copy of this form and check made payable to : West Virginia Poison Center . For more information email us at  Diana Ramsey or call (304) 347-1212. Please send this completed order form along with any required payment to :
West Virginia Poison Center
Robert C. Byrd HSC of West Virginia University
3110 MacCorkle Ave SE
Charleston, WV 25304


  Certified as a Regional Poison Control Center by the
American Association of Poison Control Centers.