Store It Safe: Take the Pledge

First Name *

Last Name *

Email *

Phone

Zip Code

May Ohio AAP contact you for follow-up feedback and to provide updated content and information?

Yes

Would you like the Ohio AAP to contact you with additional information on applying for free gun boxes?

Yes

Best Follow-Up Contact (If not yourself)

Follow-up Contact Email (If not yourself)

Please check the box that best fits your role

Physician/Provider

Non-Physician Community Partners

Practice Name

Type of Provider Type of Provider

Practice Size

Number of Teens You Personally See Weekly? (Approximately) Number of Teens You Personally See Weekly? (Approximately)

Practice Location

Rural

Suburban

Urban - Inner City

Urban - Non-Inner City

By taking the Store It Safe Pledge, I Pledge to:

Screen every teen for depression at every visit

Provide appropriate Ohio AAP SIS resources

Offer gun boxes OR discuss importance of gun boxes with teens & family

Organization Name

Organization Location

Rural

Suburban

Urban-Inner City

Urban-Non-Inner City

Number of Teens You Personally See Weekly? (Approximately)

By taking the Store It Safe Pledge, I Pledge to:

Discuss Store It Safe and the importance of firearm safety with friends, family, or colleagues

Share SIS updates, news, and information on social media

Participate in SIS advocacy activities

#StoreItSafePledge