Barron County Community Coalition Membership Agreement

2017 Barron County Community Coalition Membership Agreement

The Barron County Community Coalition welcomes everyone! We would love to have you join us. Sign up or share this with someone you think may be interested.

Question Title

* 1. Member information

Name (First and Last)

Organization

Address

City/Town

State/Province

ZIP/Postal Code

Email Address

Phone Number

Question Title

* 2. In what school district do you reside?

Question Title

* 3. How long have you been a member of the coalition?

Less than 1 year

1-4 years

5-9 years

10 years or more

Not applicable

Don't know

Question Title

* 4. How long has your agency been a member of the coalition?

Less than 1 year

1-4 years

5-9 years

10 years or more

Not applicable

Don't know

Question Title

* 5. Please select your prefered level of membership

Active Member: I would like become/continue to be an active member of the Barron County Community Coalition. I will attend meetings regularly and will be involved in the work of the Coalition. I will be an advocate for the Coalition. I will support the mission and promote the work of the coalition. As an active member I will receive Community Coalition meeting reminders, meeting minutes and informational mailings such as; notices of upcoming events, meetings and training opportunities as well as share coalition information, programming and opportunities with my networks.

Supporting Member: I will attend occasional meetings. I wish to be familiar with the work of the coalition and support Coalition efforts. As a supporting member, I will receive Community Coalition meeting reminders, meeting minutes and informational mailings such as; notices of upcoming events, meetings and training opportunities as well as share coalition information, programming and opportunities with my networks.

Extended Member: I am not able to attend meetings but I am willing to be contacted occasionally regarding specific prevention issues and volunteer opportunities. I will receive Community Coalition meeting reminders, meeting minutes and informational mailings such as; notices of upcoming events, meetings and training opportunities as well as share coalition information, programming and opportunities with my networks.

Please remove me from your mailing list. I am not interested in involvement with the Barron County Community Coalition at this time.

Question Title

* 6. Please indicate the community sector that best describes you (Choose all that apply):

Youth

Business

School

Law Enforcement

Civic or Volunteer group

Parent

Media

Youth Serving Organization

Religious or Fraternal Organization

Healthcare Professional

State, Local, Tribal Governmental Agency with Expertise in the Field of Substance Abuse

Other Organization Involved in Reducing Substance Abuse

Question Title

* 7. Please indicate the community sector that best describes you (Choose all that apply):

Youth

Business

School

Law Enforcement

Civic or Volunteer group

Parent

Media

Youth Serving Organization

Religious or Fraternal Organization

Healthcare Professional

State, Local, Tribal Governmental Agency with Expertise in the Field of Substance Abuse

Other Organization Involved in Reducing Substance Abuse

Question Title

* 8. Please list other community organizations you are involved with. For example civic groups, church groups, etc

Civic Club:

Religious Group:

Volunteer Group:

Community Group:

School Group:

Other Organization Involved in Reducing Substance Abuse:

Other:

Question Title

* 9. I give permission to be identified as a member of the Coalition (by name and/or photo) in any print, radio, or television coverage

Yes

Question Title

* 10. If there is anyone you reccomend Barron County Community Coalition reach out and invite to join the coaltition, please provide their contact information. (Name and Email Address)

Question Title

* 1. Member information

Question Title

* 2. In what school district do you reside?

Question Title

* 3. How long have you been a member of the coalition?

Question Title

* 4. How long has your agency been a member of the coalition?

Question Title

* 5. Please select your prefered level of membership

Question Title

* 6. Please indicate the community sector that best describes you (Choose all that apply):

Question Title

* 7. Please indicate the community sector that best describes you (Choose all that apply):

Question Title

* 8. Please list other community organizations you are involved with. For example civic groups, church groups, etc

Question Title

* 9. I give permission to be identified as a member of the Coalition (by name and/or photo) in any print, radio, or television coverage

Question Title

* 10. If there is anyone you reccomend Barron County Community Coalition reach out and invite to join the coaltition, please provide their contact information. (Name and Email Address)

Question Title

* 11. Other Comments: