Prevention Programs Request Form
Please fill in the following information to request a presentation or activity from The Council's Prevention Programs.

When possible please allow a minimum notice of two weeks prior to the date requesting to better help us meet your need.

If you have any trouble with this form please email: b.tinney@recoverycouncil.org
Thank you.
Organization Name *
Which county are you in? *
Please select ALL that apply.
Required
Name *
Title
Email *
Phone number *
Activity *
Location/ Facility *
Please include address as well as the name
Date(s) requesting *
If you do not have a specific date please provide the best day of the week. Also provide when you want the presentation (i.e. a specific week in March).
Time *
If you do not have a specific time please provide the best time of day. Also include how long the presentation/activity will be (i.e. 45 minutes)
Audience *
Please select ALL that apply
Required
If this activity is for students, please indicate which grades below.
If this activity is for Faculty/Staff please indicate if they need Continuing Education for any of the following:
Please select ALL that apply
Presentation Topic
* If this is for a presentation request, please select ALL that apply.
If this is for a Resource or Health Fair, please check ALL that apply:
If this is for a presentation, assembly or other activity, please indicate what technology accommodations you can provide.
This is for our planning purposes. Our Prevention Specialists need to know whether to bring a laptop or just their USB drive with their presentation. Please select ALL that apply
Additional Information
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