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.
What is your job title?
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?
Representative of an agency/organization
If you are representing an agency/organization please specify:
Please indicate what sector of the community you represent (you may select more than 1):
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 college)
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 legally 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 sworn in law enforcement officer, not retired)
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 abuse through prevention, treatment, and/or recovery)
Business (an individual working for or representing a business)
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