PCMC Membership Form

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The Prevention Coalition of Monmouth County (PCMC) is a forum for community members and organizations with the express purpose of working together to reduce substance misuse in Monmouth County. The PCMC is charged with developing strategic plan to reduce substance use/misuse through sustainable prevention programs and strategies, increasing public awareness related to substance misuse trends and community resources and effecting community-level change through policy advocacy efforts.

For additional information, please contact GiAnna Rossano, Community Development Specialist at grossano@preventionfirst.net.

Individual Name and Title *

Name of Organization *

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) *

Referred by

Address *

Telephone # *

Fax #

E-mail Address *

I am interested in the following areas topics: (Click all that apply) *

Underage Drinking/Marijuana/Tobacco ENDS

Opioid Use/Misuse

New and Emerging Drugs/Trends

Sustainability

Other:

Required

What sector of the community do you represent? *

Business

Civic or Volunteer Group

Education

State, Local, or Tribal Government Agency

Healthcare Professional

Law Enforcement

Media

Parent

Faith-based organization

Youth Serving Organization

Youth

Concerned Resident

Other Organization Involved in Reducing Substance Abuse

How can PCMC collaborate more with your organization?

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 both the PCMC and on or more of its focus areas. I understand that I or my designated representative is expected to attend at least 50% of PCMC meetings, as per PCMC by-laws. If for some reason one of us cannot attend 50% of the meetings, I agree to supplement my support by participating in another approved PCMC event or activity. 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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