PCMC Membership Form 
The Prevention Coalition of Monmouth County (PCMC) is a forum for community members and organizations that has the express purpose of working together to reduce substance misuse in Monmouth County. The PCMC is charged with developing a strategic plan to reduce substance use/misuse through sustainable prevention programs and strategies, increasing public awareness related to substance misuse trends, providing community resources, and effecting community-level change through policy advocacy efforts. 
For additional information, please contact GiAnna Rossano, Regional Coalition Coordinator, at grossano@preventionfirst.net. 
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Individual Name and Title  *
E-mail Address *
Alternative Representative Name (We ask that if you are unable to attend a meeting that you will have an alternative sit in on the meeting in your place)  *
How did you hear about PCMC?  *
Address *
Telephone # *
Fax #
What sector of the community do you represent?  *
Name of Organization (If applicable) 
I am interested in joining a task force of the coalition: (Click all that apply)
How do you feel you or your organization can benefit from being a PCMC member? 
Thank you for your interest in becoming a PCMC member
By submitting this form, I agree to participate in the Prevention Coalition of Monmouth County and receive Coalition emails to the address given above. I give permission for my image to be used on any coalition related promotional materials, social media, press releases, and/or other marketing materials. 
Please sign your name below to acknowledge you have reviewed and agree to member by-laws of the Prevention Coalition of Monmouth County.  *
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