Join the Parents Connecting Network!

Commit to protecting your child from the dangers of underage drinking and connect with other parents who feel the same. For more information about the Network visit www.getinvolvedASAP.org

Question Title

* 1. I/We agree to not allow alcohol to be used by anyone under age 21 in our home or on our property, and would like to have our names placed in the Parents Connecting Network Directory.

Yes

Please provide the following information to be included in the network directory:

Question Title

* 2. Parent/Guardian 1

First Name

Last Name

Phone Number

Question Title

* 3. Parent/Guardian 2

First Name

Last Name

Phone Number

Question Title

* 4. Your Child (1)

First Name

Last Name

Year of Graduation

Name of School

Question Title

* 5. Your Child (2)

First Name

Last Name

Year of Graduation

Name of School

Question Title

* 6. Your Child (3)

First Name

Last Name

Year of Graduation

Name of School

Question Title

* 7. Your Child (4)

First Name

Last Name

Year of Graduation

Name of School

Please answer the following - this information will NOT be included in the directory.

Question Title

* 8. Please give the email you would like your directory to be sent to (this will not be included in the directory itself).

Email:

Question Title

* 9. If you don't have an email address, please provide the address to mail your directory to (this will not be included in the directory itself).

Street Address

City

State

Zip

Question Title

* 10. I would like to opt out of periodically receiving the More Kids Drug Free electronic newsletter that gives current information to help me encourage my kids to be alcohol and drug free.

Opt out

Question Title

* 11. By typing my full name in this box I confirm that I want to join the Parents Connecting Network.
I understand that:
a) Directory information will only be shared with participants and will include families across Eau Claire County
b) Updates of the directory will take place each fall
c) Membership in the Parents Connecting Network is continuous throughout my child's school career, but I may opt out any time via email to lilliam.Pinero@co.eau-claire.wi.us or calling 715-839-5091

I confirm that I want to join the Parents Connecting Network