PRC September Request Form
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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:
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:
2
. Your Information
Your Information
Name:
School:
Shipping Address:
Address 2:
City/Town:
ZIP:
Email Address:
Phone Number:
*
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
County school is located in:
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.
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
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
DETAILED Menu: (use either the Basic Components or the Detailed listing - not both) Alcohol Brochures
1
5
10
15
25
Spanish
Elementary
4-6 Grades
7-9 Grades
10-12 Grades
1-6 Grades
7-12 Grades
Adults
Children
Youth
All
For Grades
Club Drugs
5
10
25
50
75
100
125
Club Drugs Brochures
1
5
10
15
25
Spanish
Elementary
4-6 Grades
7-9 Grades
10-12 Grades
1-6 Grades
7-12 Grades
Adults
Children
Youth
All
For Grades
Cocaine
5
10
25
50
75
100
125
Cocaine Brochures
1
5
10
15
25
Spanish
Elementary
4-6 Grades
7-9 Grades
10-12 Grades
1-6 Grades
7-12 Grades
Adults
Children
Youth
All
For Grades
Crack
5
10
25
50
75
100
125
Crack Brochures
1
5
10
15
25
Spanish
Elementary
4-6 Grades
7-9 Grades
10-12 Grades
1-6 Grades
7-12 Grades
Adults
Children
Youth
All
For Grades
Crystal
5
10
25
50
75
100
125
Crystal Brochures
1
5
10
15
25
Spanish
Elementary
4-6 Grades
7-9 Grades
10-12 Grades
1-6 Grades
7-12 Grades
Adults
Children
Youth
All
For Grades
HIV/AIDS
5
10
25
50
75
100
125
HIV/AIDS Brochures
1
5
10
15
25
Spanish
Elementary
4-6 Grades
7-9 Grades
10-12 Grades
1-6 Grades
7-12 Grades
Adults
Children
Youth
All
For Grades
Inhalants/Huffing
5
10
25
50
75
100
125
Inhalants/Huffing Brochures
1
5
10
15
25
Spanish
Elementary
4-6 Grades
7-9 Grades
10-12 Grades
1-6 Grades
7-12 Grades
Adults
Children
Youth
All
For Grades
Marijuana
5
10
25
50
75
100
125
Marijuana Brochures
1
5
10
15
25
Spanish
Elementary
4-6 Grades
7-9 Grades
10-12 Grades
1-6 Grades
7-12 Grades
Adults
Children
Youth
All
For Grades
Meth
5
10
25
50
75
100
125
Meth Brochures
1
5
10
15
25
Spanish
Elementary
4-6 Grades
7-9 Grades
10-12 Grades
1-6 Grades
7-12 Grades
Adults
Children
Youth
All
For Grades
RX Drugs
5
10
25
50
75
100
125
RX Drugs Brochures
1
5
10
15
25
Spanish
Elementary
4-6 Grades
7-9 Grades
10-12 Grades
1-6 Grades
7-12 Grades
Adults
Children
Youth
All
For Grades
Rohypnol
5
10
25
50
75
100
125
Rohypnol Brochures
1
5
10
15
25
Spanish
Elementary
4-6 Grades
7-9 Grades
10-12 Grades
1-6 Grades
7-12 Grades
Adults
Children
Youth
All
For Grades
Steroids
5
10
25
50
75
100
125
Steroids Brochures
1
5
10
15
25
Spanish
Elementary
4-6 Grades
7-9 Grades
10-12 Grades
1-6 Grades
7-12 Grades
Adults
Children
Youth
All
For Grades
Smokeless Tobacco
5
10
25
50
75
100
125
Smokeless Tobacco Brochures
1
5
10
15
25
Spanish
Elementary
4-6 Grades
7-9 Grades
10-12 Grades
1-6 Grades
7-12 Grades
Adults
Children
Youth
All
For Grades
Tobacco
5
10
25
50
75
100
125
Tobacco Brochures
1
5
10
15
25
Spanish
Elementary
4-6 Grades
7-9 Grades
10-12 Grades
1-6 Grades
7-12 Grades
Adults
Children
Youth
All
For Grades
Getting Help!
5
10
25
50
75
100
125
Getting Help! Brochures
1
5
10
15
25
Spanish
Elementary
4-6 Grades
7-9 Grades
10-12 Grades
1-6 Grades
7-12 Grades
Adults
Children
Youth
All
For Grades
6
. Children workbooks (limited stock)
5
10
25
Being Me and Tobacco Free Grades 1-4
*
Children workbooks (limited stock) 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
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:
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
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
Which posters would you like to receive? Stickers, children's activity books and other available items will be added also (as supplies last): Drugs are Dumb Quantity
Bunny: (drugs, meth, alcohol, smoking, vomit)
1
5
10
15
Bunny: (drugs, meth, alcohol, smoking, vomit) Quantity
Surprised you're hooked
1
5
10
15
Surprised you're hooked Quantity
Ecstasy
1
5
10
15
Ecstasy Quantity
Your drink you lose
1
5
10
15
Your drink you lose Quantity
Buying tobacco, lose your license
1
5
10
15
Buying tobacco, lose your license Quantity
Drunk Driving
1
5
10
15
Drunk Driving Quantity
Pot mayks you stoopid
1
5
10
15
Pot mayks you stoopid Quantity
Steroids
1
5
10
15
Steroids Quantity
9
. How else can Prevention Resource Center be of assistance to you? We'll send you the link to complete that form for details:
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)
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