Henry County LIVE Coalition (HCLC) Member Application

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Henry County LIVE Coalition (HCLC) Member Application

OUR COMMITMENT TO HENRY COUNTY

Mission: To unify all members of our community in creating conditions that foster resilience, reduce substance misuse, and promote mental health and well-being. We are dedicated to preventing substance misuse and suicide through community-wide collaboration, education, and the strengthening of supportive networks for all residents.

Vision: A community free from stigma and the generational impact of substance misuse, where every individual feels supported on their journey toward a healthier, brighter future.

Which best describes you? *

I am a current HCLC member reactivating my membership.

I am a current HCLC member but am not receiving email communications.

I am a new HCLC member and need to be added onto email lists.

Other:

Tell us a little bit about yourself

Name *

Email Address *

Phone Number *

Birthday (Month & Day)

Address

Zip Code *

Please indicate which sector(s) of the community you represent (you may select more than one):
*

Healthcare (an individual and/or representative of an organization that is licensed to provide physical, mental or behavioral healthcare services)

Education (a representative of a school system pre-K through high education)

Youth Serving Organizations (a representative of an organization that provides services to youth)

Volunteer/Civic Organizations (a representative of an organization that provides civic or volunteer activities that serves the community)

Religious/Fraternal Organizations (a representative of a faith-based organization or a fraternal organization)

Parent (an individual responsible for a child, grandchild or foster child)

Youth (an individual 18 years of age or younger)

Law Enforcement (a representative that is an active or retired sworn in law enforcement officer)

Media (a representative of a communication outlet that provides information to the community)

Organization Focused on Alcohol & Drug Issues (a representative of a community organization that addresses substance use through prevention, treatment and/or recovery)

Government

Business

Required

Professional Background and/or Community Experience

Agency/Organization (If you are joining as an individual and not a representative of an organization, please write: "individual")
*

Job Title or Community Role (volunteer, concerned parent, etc.)

Do you have any professional licenses/credentials that you wish to list?

RA/OCPSA/OCPS/OCPC

LSW/LISW/MSW

CHES/MCHES

RN/APN

MPH

PhD

Other:

Member Involvement

I will participate in bimonthly meetings of the full membership. I will make my best effort to attend all meetings whenever possible. I understand that attending no meetings over a period of 6 months will make me an inactive member of the coalition.
*

Yes

I would like to participate in coalition subcommittees of interest. This would require participation in monthly meetings and communication via email. (Please select all that apply).
*

Alcohol Prevention

Tobacco Prevention

Mental Health / Suicide Prevention

I am not interested in participating in subcommittees at this time.

Required

I can serve as a subject area expert and am willing to provide training on the below topics (please select all that apply).

Alcohol Prevention

Tobacco Prevention

Mental Health/Wellness

Suicide Prevention

Trauma / ACE's

Advocacy / Policy

Other:

I can contribute to the HCLC in the following ways (please check all that apply):

I am willing to review drafts of materials (reports, fact sheets, position papers, etc.)

I can include HCLC information in my organization's newsletter

I can link my agency/organization's website to the HCLC webpage

I can offer meeting space

I can offer other resources (refreshments, expertise, skill). Please specify in "Additional Information" below

I would be willing to serve as a committee co-chair.

Other:

How did you hear about Henry County LIVE Coalition? *

Additional Information

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