Healthy Cattaraugus Co Coalition Member Survey

As a current or previous member of the Healthy Cattaraugus County DFC Coalition, please complete the demographic member survey below.

The Coalition is compiling a membership database that will be kept confidential and used by the Project Director to report membership demographics in an aggregate manner and to keep membership contact information updated. Individual responses will not be shared.

Thank you for your time.

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* 1. First Name

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* 2. Last Name

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* 3. Name of Organization you are representing (if applicable)

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* 4. Professional Title

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* 5. Organization (or Individual) Sector

Youth Serving Organization

Law Enforcement Agency

Healthcare Professional

Business Community

State, Local, and/or Tribal Governmental Agency

Civic or Volunteer Group

Schools

Religious or Fraternal Organization

Media

Other Organization with Substance Abuse Expertise

Parent (Individual - Private Citizen)

Youth (Individual - Private Citizen)

Other (please specify)

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* 6. Organization or Individual Contact Information

Address

Address 2

City/Town

State/Province

ZIP/Postal Code

Email Address

Phone Number

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* 7. When did you begin participating in Coalition activities?

2018

2017

2016

2015

2014

2013

2012

2011

2010

2009

Other (please specify)

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* 8. What Coalition Subcommittee do you participate on?

Executive Committee

Strategic Planning Committee

Assessment Committee

Media and Marketing Committee

Youth Advisory Committee

Other (please specify)

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* 1. First Name

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* 2. Last Name

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* 3. Name of Organization you are representing (if applicable)

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* 4. Professional Title

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* 5. Organization (or Individual) Sector

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* 6. Organization or Individual Contact Information

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* 7. When did you begin participating in Coalition activities?

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* 8. What Coalition Subcommittee do you participate on?

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* 9. Additional Comments or Notes