Montgomery County Prevention Coalition Member Application
The mission of the Montgomery County Prevention Coalition is to mobilize Montgomery County residents to prevent youth substance use and promote positive mental health through implementation of evidence-based prevention strategies and community collaboration.
Email address *
Name *
Your answer
Agency/Organization *
Your answer
Address *
Your answer
Phone Number *
Your answer
What is your job title? *
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Do you have any professional licenses/credentials that you wish to list?
Are you joining the Montgomery County Prevention Coalition as an individual or as a representative of an agency/organization? *
If you are representing an agency/organization please specify:
Your answer
Please indicate what sector of the community you represent (you may select more than 1):
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