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South Central Alliance for Tobacco Prevention Membership Survey
Help us learn more about you and your passions.
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* Indicates required question
First Name
*
Your answer
Last Name
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Your answer
Address (place of residence)
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Your answer
City
*
Your answer
State
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Your answer
Zip Code
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Your answer
Phone Number
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Your answer
Email Address
*
Your answer
Organizations (Professional and/or Personal) you belong to
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Your answer
Indicate Your Sector (All that apply)
*
Youth
School
Youth Serving Organization
Law Enforcement
Parent
Business
Religious/Fraternal
Local/State/Tribal Government
Healthcare
Media
Civic/Volunteer
Substance Abuse Agency
Other:
Required
Indicate Areas of Interest (All that apply)
*
Community outreach and education
Tabling at community fairs, festivals, and events
Special events coordination and support
Public Speaking or presentations
Social media content
Working with the local media (i.e. letter to the editor)
Policy advocacy and education
Data collection and analysis
Legislative Education/Engagement
Other:
Required
Indicate focus areas you are interested in working with (All that apply)
*
Tobacco Free Schools
Municipal E-cigarette Ordinances
Tobacco Free Outdoor Spaces
Youth Access
Retailer Licensing
Behavioral Health
Maternal Smoking
Other:
Required
What is your "why" for being a part of our alliance?
*
Your answer
Other passions, interests, or hobbies:
*
Your answer
Indicate any special skills or background that would help support our work:
*
Your answer
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