Project Prevent Youth Coalition 

Information obtained from this survey will be used to connect youth with local youth tobacco coalitions in Arkansas. Please have the name and contact information for the Advisor, or contact person, of your coalition before completing the survey.  

* 1. In what ZIP code is your coalition located? (enter 5-digit ZIP code; for example, 72202 or 72113)
If your coalition covers one or more ZIP code areas, please include all of them in your response.

* 2. What is the name of your coalition?
Please list it as you want it to appear on the Project Prevent website.

* 3. What is the name of the person responsible for coordinating your local youth coalition?
Please make sure the name is spelled correctly and includes any titles you want listed with the name (for example; Dr., MS, BSE).

* 4. What email address is associated with your coalition?
Make sure the email address is monitored frequently as it will be the most likely way that youth contact you to find out more about your coalition. 

* 5. List the phone number and/or address associated with your coalition. 

* 6. If a website is associated with your coalition, please list it here.
Please do NOT include the Project Prevent Youth Coalition website.