Connect With Prevention Pathways – Media Studio

Name

First Name

Last Name

Organization / School / Church / Community Group

Title/Role

Phone Number

Email

City/Community

Zip Code

HOW WOULD YOU LIKE TO CONNECT WITH NCADD-GDA? (Check all that apply)

WHICH PREVENTION PATHWAY ARE YOU INTERESTED IN? (Check all that apply)

Youth Voice & Empowerment

Parent & Family Support

Community & Faith Partnerships

Media & Digital Prevention

Not sure — help me determine the best fit

Type of organization/community

What are you requesting?

Proposed event/program date

Proposed start/end time

Event location/address

Estimated number of participants

Participant age range

Is the event open to the public?

Yes

No

Brief description of the event, audience or need.

What are you interested in creating?

Who will participate?

Estimated number of participants

Preferred timeframe/date

Briefly describe your idea.

Do you need NCADD’s help developing the concept?

Yes

No

Not Sure

Anything else we should know?

How did you hear about NCADD-GDA?