* 1. How concerned are you about preventing underage drinking and marijuana use in North Berkshire?

* 2. What substances do you think youth in our community are most likely to use? (check all that apply)

* 3. Which of the following substances would you like to learn more about regarding the risks of youth use? (circle all that apply)

* 4. Do you talk to your child about alcohol or other drug use?

* 5. Do you talk to other parents about concerns you have about alcohol or other drug use by youth?

* 6. How likely are you to participate in the following oportunities to prevent underage drinking and marijuana use?

  Very likely Somewhat likely Not likely
A 5 week class with other parents (dinner and childcare provided)
Forums with expert speakers to give information on specific substances and prevention strategies
Gatherings with other parents to talk about parenting health children
Be part of a community work group to prevent youth alcohol and drug use

* 7. How many children do you have and what are their ages?

* 8. Name (optional)

* 9. E-mail address (optional)

* 10. Would you like to be added to an email list for information about programming and strategies to prevent underage drinking and drug use in North Berkshire?

* 11. Thank you! Please share any other comments or questions pertaining to preventing underage drinking and drug use in your community