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:
Thank you.
Organization Name *
Which county are you in? *
Please select ALL that apply.
Name *
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
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
Never submit passwords through Google Forms.
This content is neither created nor endorsed by Google. Report Abuse - Terms of Service - Privacy Policy