PA Stop & PA Start Media Request Form

Question Title

1. What campaign are you considering for your media messaging? (Required.)

PA Stop

PA Start

Both

Not Sure

Question Title

2. Contact Information (Required.)

Your Name *

Agency/Coalition *

Address *

City/Town *

State/Province

ZIP/Postal Code *

County *

Email Address *

Phone Number *

Question Title

3. Agency/Coalition Description (Required.)

SCA

Prevention Provider

Communities that Care Coalition

OMPP Coalition

Drug Free Communities Coalition

Overdose Prevention Coalition

Other Prevention Coalition

Recovery Organization/Coalition

Treatment Organization/Coalition

Business

Other Non Profit

Other (please specify)

Question Title

4. What audiences do you want to target with the media materials? (Required.)

Collegiate Personnel

Community

Faith Based Organizations

Families

LGBTQI Community

Recovery Community

School Personnel (K-12)

Youth

Other (please specify)

Question Title

5. What is the target age range? (Required.)

17 and younger

18-25

26-64

65 and older

Other (please be specific, e.g. 12-15-year-olds)

Question Title

6. What is your goal for the media campaign? (Required.)

Increase Collaboration with Faith Based Organizations

Increase Collaboration with other Community Based Organizations

Promote & Market your Programs, Events, or Initiatives

Provide Education

Provide Information about Available Community Resources

Reducing Stigma

Raise Awareness of Prescription Drug Misuse

Other (please specify)

Question Title

7. What type of media materials are you considering? (Required.)

Outdoor Advertising (i.e. billboards, transit)

Postcards & Direct Mail

Printed Materials

Social Media Content

Tactile Handouts (i.e. brochures, toolkits, posters)

Video and/or Radio PSA's

Web Ads

Other (please specify)

Question Title

8. Do you want customized media materials to include your logo, website, phone number, etc.? (Required.)

Yes.

No. I prefer something prepared and accessible.

Question Title

9. Do you have an approximate date range for your campaign?

Yes

I'm flexible

PA Stop & PA Start Media Request Form

Question Title

* 1. What campaign are you considering for your media messaging? (Required.)

Question Title

* 2. Contact Information (Required.)

Question Title

* 3. Agency/Coalition Description (Required.)

Question Title

* 4. What audiences do you want to target with the media materials? (Required.)

Question Title

* 5. What is the target age range? (Required.)

Question Title

* 6. What is your goal for the media campaign? (Required.)

Question Title

* 7. What type of media materials are you considering? (Required.)

Question Title

* 8. Do you want customized media materials to include your logo, website, phone number, etc.? (Required.)

Question Title

* 9. Do you have an approximate date range for your campaign?

1. What campaign are you considering for your media messaging? (Required.)

2. Contact Information (Required.)

3. Agency/Coalition Description (Required.)

4. What audiences do you want to target with the media materials? (Required.)

5. What is the target age range? (Required.)

6. What is your goal for the media campaign? (Required.)

7. What type of media materials are you considering? (Required.)

8. Do you want customized media materials to include your logo, website, phone number, etc.? (Required.)

9. Do you have an approximate date range for your campaign?