PRC September Request Form Question Title * 1. Providing resources to our community is our mission: to educate, engage and encourage. Please complete this request form for literature and brochures. Items such as stickers, bookmarks, etc. will be included based on availability.These are at no costs to you and your agency, however, remember we serve 23 East Texas counties. All requests are based on inventory and grant funding.Your initials here to confirm acknowledgment of this information: Question Title * 2. Your Information Name: School: Shipping Address: Address 2: City/Town: ZIP: Email Address: Phone Number: Question Title * 3. County school is located in: Anderson Bowie Camp Cass Cherokee Delta Franklin Gregg Harrison Henderson Hopkins Lamar Marion Morris Panola Rains Red River Rusk Smith Titus Upsur Van-Zandt Wood Question Title * 4. Would you like to receive a sample package of age appropriate material? This will be delivered with your Red Ribbon Week supplies in September. Yes Not at this time Question Title * 5. DETAILED Menu: (use either the Basic Components or the Detailed listing - not both) Brochures Spanish For Grades Alcohol 5 10 25 50 75 100 125 Alcohol Brochures menu 1 5 10 15 25 Alcohol Spanish menu Elementary 4-6 Grades 7-9 Grades 10-12 Grades 1-6 Grades 7-12 Grades Adults Children Youth All Alcohol For Grades menu Club Drugs 5 10 25 50 75 100 125 Club Drugs Brochures menu 1 5 10 15 25 Club Drugs Spanish menu Elementary 4-6 Grades 7-9 Grades 10-12 Grades 1-6 Grades 7-12 Grades Adults Children Youth All Club Drugs For Grades menu Cocaine 5 10 25 50 75 100 125 Cocaine Brochures menu 1 5 10 15 25 Cocaine Spanish menu Elementary 4-6 Grades 7-9 Grades 10-12 Grades 1-6 Grades 7-12 Grades Adults Children Youth All Cocaine For Grades menu Crack 5 10 25 50 75 100 125 Crack Brochures menu 1 5 10 15 25 Crack Spanish menu Elementary 4-6 Grades 7-9 Grades 10-12 Grades 1-6 Grades 7-12 Grades Adults Children Youth All Crack For Grades menu Crystal 5 10 25 50 75 100 125 Crystal Brochures menu 1 5 10 15 25 Crystal Spanish menu Elementary 4-6 Grades 7-9 Grades 10-12 Grades 1-6 Grades 7-12 Grades Adults Children Youth All Crystal For Grades menu HIV/AIDS 5 10 25 50 75 100 125 HIV/AIDS Brochures menu 1 5 10 15 25 HIV/AIDS Spanish menu Elementary 4-6 Grades 7-9 Grades 10-12 Grades 1-6 Grades 7-12 Grades Adults Children Youth All HIV/AIDS For Grades menu Inhalants/Huffing 5 10 25 50 75 100 125 Inhalants/Huffing Brochures menu 1 5 10 15 25 Inhalants/Huffing Spanish menu Elementary 4-6 Grades 7-9 Grades 10-12 Grades 1-6 Grades 7-12 Grades Adults Children Youth All Inhalants/Huffing For Grades menu Marijuana 5 10 25 50 75 100 125 Marijuana Brochures menu 1 5 10 15 25 Marijuana Spanish menu Elementary 4-6 Grades 7-9 Grades 10-12 Grades 1-6 Grades 7-12 Grades Adults Children Youth All Marijuana For Grades menu Meth 5 10 25 50 75 100 125 Meth Brochures menu 1 5 10 15 25 Meth Spanish menu Elementary 4-6 Grades 7-9 Grades 10-12 Grades 1-6 Grades 7-12 Grades Adults Children Youth All Meth For Grades menu RX Drugs 5 10 25 50 75 100 125 RX Drugs Brochures menu 1 5 10 15 25 RX Drugs Spanish menu Elementary 4-6 Grades 7-9 Grades 10-12 Grades 1-6 Grades 7-12 Grades Adults Children Youth All RX Drugs For Grades menu Rohypnol 5 10 25 50 75 100 125 Rohypnol Brochures menu 1 5 10 15 25 Rohypnol Spanish menu Elementary 4-6 Grades 7-9 Grades 10-12 Grades 1-6 Grades 7-12 Grades Adults Children Youth All Rohypnol For Grades menu Steroids 5 10 25 50 75 100 125 Steroids Brochures menu 1 5 10 15 25 Steroids Spanish menu Elementary 4-6 Grades 7-9 Grades 10-12 Grades 1-6 Grades 7-12 Grades Adults Children Youth All Steroids For Grades menu Smokeless Tobacco 5 10 25 50 75 100 125 Smokeless Tobacco Brochures menu 1 5 10 15 25 Smokeless Tobacco Spanish menu Elementary 4-6 Grades 7-9 Grades 10-12 Grades 1-6 Grades 7-12 Grades Adults Children Youth All Smokeless Tobacco For Grades menu Tobacco 5 10 25 50 75 100 125 Tobacco Brochures menu 1 5 10 15 25 Tobacco Spanish menu Elementary 4-6 Grades 7-9 Grades 10-12 Grades 1-6 Grades 7-12 Grades Adults Children Youth All Tobacco For Grades menu Getting Help! 5 10 25 50 75 100 125 Getting Help! Brochures menu 1 5 10 15 25 Getting Help! Spanish menu Elementary 4-6 Grades 7-9 Grades 10-12 Grades 1-6 Grades 7-12 Grades Adults Children Youth All Getting Help! For Grades menu Question Title * 6. Children workbooks (limited stock) 5 10 25 Being Me and Tobacco Free Grades 1-4 Being Me and Tobacco Free Grades 1-4 5 Being Me and Tobacco Free Grades 1-4 10 Being Me and Tobacco Free Grades 1-4 25 Drugs Can't Stop Me Ages 6-9 Drugs Can't Stop Me Ages 6-9 5 Drugs Can't Stop Me Ages 6-9 10 Drugs Can't Stop Me Ages 6-9 25 Tobacco is Trash Grades 4-8 Tobacco is Trash Grades 4-8 5 Tobacco is Trash Grades 4-8 10 Tobacco is Trash Grades 4-8 25 Tobacco Smash It! Grades 4-8 Tobacco Smash It! Grades 4-8 5 Tobacco Smash It! Grades 4-8 10 Tobacco Smash It! Grades 4-8 25 Tobacco Stinks Grades 4-8 Tobacco Stinks Grades 4-8 5 Tobacco Stinks Grades 4-8 10 Tobacco Stinks Grades 4-8 25 Question Title * 7. SOS: Spotlight On Smokeless is a curriculum that can be used in your school to give youth (grades 1-6) the knowledge and skills needed to resist smokeless tobacco use. (Notice-our new grant does not offer stipends.) These are free! Please write the quantity you need: Teacher's guide Student's workbook Question Title * 8. Which posters would you like to receive? Stickers, children's activity books and other available items will be added also (as supplies last): Quantity Drugs are Dumb 1 5 10 15 Drugs are Dumb Quantity menu Bunny: (drugs, meth, alcohol, smoking, vomit) 1 5 10 15 Bunny: (drugs, meth, alcohol, smoking, vomit) Quantity menu Surprised you're hooked 1 5 10 15 Surprised you're hooked Quantity menu Ecstasy 1 5 10 15 Ecstasy Quantity menu Your drink you lose 1 5 10 15 Your drink you lose Quantity menu Buying tobacco, lose your license 1 5 10 15 Buying tobacco, lose your license Quantity menu Drunk Driving 1 5 10 15 Drunk Driving Quantity menu Pot mayks you stoopid 1 5 10 15 Pot mayks you stoopid Quantity menu Steroids 1 5 10 15 Steroids Quantity menu Question Title * 9. How else can Prevention Resource Center be of assistance to you? We'll send you the link to complete that form for details: Classroom/assembly speaker How to Volunteer information Information booth/fair Staff training event ETCADA overview Tobacco Prevention Community Coalition Youth Prevention Programs Red Ribbon Week resources (for those who have not ordered yet) Other (please specify) Done