Montgomery County Prevention Coalition Member Application

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The mission of the Montgomery County Prevention Coalition is to mobilize Montgomery County residents to prevent youth substance use and promote positive mental health through implementation of evidence-based prevention strategies and community collaboration.

Email *

Name *

Agency/Organization *

Address *

Zip Code

Phone Number *

What is your job title? *

Do you have any professional licenses/credentials that you wish to list?

RA/OCPSA/OCPS/OCPC

LSW/LISW/MSW

CHES/MCHES

RN/APN

MPH

PhD

Other:

Are you joining the Montgomery County Prevention Coalition as an individual or as a representative of an agency/organization? *

Individual

Representative of an agency/organization

If you are representing an agency/organization please specify:

Please indicate what sector of the community you represent (you may select more than 1):

Healthcare (an individual and/or representative of an organization that is licensed to provide physical, mental, or behavioral healthcare services)

Education (a representative of a school-system pre-k through college)

Youth Serving Organizations (a representative of an organization that provides services to youth)

Volunteer/ Civic Organizations (a representative of an organization that provides civic or volunteer activities that serves the community)

Religious/ Fraternal Organizations (a representative of a faith-based organization or a fraternal organization)

Parent (an individual legally responsible for a child, grandchild, or foster child)

Youth (an individual 18 years of age or younger)

Law Enforcement (a representative that is an active sworn in law enforcement officer, not retired)

Media (a representative of a communication outlet that provides information to the community)

Organization Focused on Alcohol & Drug Issues (a representative of a community organization that addresses substance abuse through prevention, treatment, and/or recovery)

Government

Business (an individual working for or representing a business)

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