Take Back Event Host Form
Thank you for partnering with Michigan OPEN to bring a Take Back Event to your community! We truly appreciate you taking the time to host an event.

Please read the following information, and complete the form to acknowledge your partnership with Michigan OPEN to host a Medication Take Back Event on October 26, 2019.

Email address *
I agree to the Take Back Event date and time: Saturday, October 26, 2019 from 10am-2pm *
Webinar Schedule
To support the planning of your event, Michigan OPEN will host four webinars covering various parts of the planning and implementation process. The dates and times of the webinars are as follows

o Tuesday, September 24th, 1:30-2:30 pm - Venue, Volunteers and Law Enforcement
o Monday, September 30th, 9:30-10:30 am - Promotional Efforts
o Monday October 14th, 9:30-10:30 am - Day of Logistics and Follow-Up

Hosting Information
What is the name of your organization? *
Your answer
In which county will your event take place? *
Your answer
Have you hosted a Take Back Event with Michigan OPEN previously? *
Who is the primary point of contact for planning your event? (first & last name) *
Your answer
Point of contact phone *
Your answer
Point of contact email *
Your answer
Event Location
If you have already secured a location for your event, please provide the following information. If you have not secured a location, please leave this section blank.
Event Location Name
Your answer
Event Location Address
Your answer
Law Enforcement
If you have already secured support from local law enforcement for the day of your event, please provide the following information. If you have not yet secured support from local law enforcement, please leave this section blank.
Law Enforcement Agency
Your answer
Point of contact (first & last name)
Your answer
Point of contact phone-preferably cell
Your answer
Point of contact email
Your answer
Do you need help securing law enforcement?
If there is any other information you would like to share with us about your event or organization, please include it below:
Your answer
Thank you for your partnership!!
A copy of your responses will be emailed to the address you provided.
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