Join a Coalition Group – Drug Free Pickaway

Name(Required)

First Last

Email(Required)

Phone(Required)

Address(Required)

Street Address Address Line 2 City State ZIP Code

Which best describes you?(Required)

I am a current PAAC member reactivating my membership

I am a current PAAC member but am not receiving email communications. HELP!

I am interested in becoming a PAAC member.

Other

Please indicate which sector(s)of the community you represent(Required)

Select all that apply.

Job Title or Community Role(Required)

Professional Background and/or Community Experience

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

How would you like to join the coalition?(Required)

As an individual

As a member of an organization

Agency/Organization(Required)

Tell us a little about yourself

Member Involvement

I will participate in monthly meetings of the full membership. I will make my best effort to attend all meetings whenever possible. I understand that attending no meetings over a period of 6 months will make me an inactive member of the coalition.(Required)

Yes

I would like to participate in existing coalition committees of interest. This would require participation in monthly meetings and communication via email or conference call in between meeting dates.(Required)

Select all that apply.

Alcohol Prevention

Tobacco Prevention

I am not interested in participating on committees at this time

I can contribute to PAAC in the following ways:(Required)

Select all that apply.

I am willing to review drafts of materials (reports, fact sheets, position papers, etc)

I can include PAAC information in my organization's newsletter

I can link my agency/organization's website to the PAAC webpage

I can serve as a link to specific populations for information disseminiation, program promotion, advocay efforts, etc. (Please specific the population in "Additional Information" below)

I can offer other resources (refreshments, expertise, skill) Please specifiy in "Additional Information" below

I would be willing to serve as a committee co-chair

Other

How did you hear about the Pickaway Addiction Action Coalition?