Montgomery County Prevention Coalition Member Application

JavaScript isn't enabled in your browser, so this file can't be opened. Enable and reload.

OUR COMMITMENT TO MONTGOMERY COUNTY

The Montgomery County Prevention Coalition is comprised of community leaders with a passion to prevent substance misuse and promote positive mental health. The mission of the coalition is to mobilize Montgomery County to prevent youth substance use and promote positive mental health through implementation of evidence-based prevention strategies and community collaboration.

The vision of the coalition is a community where every individual lives a substance-free life with optimal mental health.

Which best describes you: *

I am a current MCPC member reactivating my membership.

I am a current MCPC member but am not receiving email communications. Help!

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

Other:

Tell us a little about yourself.

Name *

Email Address *

Phone Number *

Birthday (just day and date is fine!) *

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:

Clear form

Never submit passwords through Google Forms.

This content is neither created nor endorsed by Google. - Terms of Service - Privacy Policy

Does this form look suspicious? Report

Forms