Fremont County Prevention Program Event/Program/Project Report
Organization
*
Name of Person Completing
*
First Name
Last Name
Email
*
example@example.com
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Begin Date
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
End Date
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Description of Event:
*
Focus Area(s)
*
All: ATODS
Alcohol
Tobacco
Other Drugs
Suicide Prevention
Total Number of Participants:
*
Demographics
Gender
Male
*
Female
*
Other/Unknown
*
Race
Asian
*
Black
*
White
*
Native American
*
Pacific Islander
*
More than one race
*
Unknown
*
Age
5 to 11
*
12 to 14
*
15 to 17
*
18 to 20
*
21 to 24
*
25 to 44
*
45 to 64
*
65 plus
*
Unknown
*
Purchases/Expenditure
Configurable list
Total Cost (All cost from table above)
Attach a sign in sheet/roster of the event
*
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ATTACH ALL SUPPORTING DOCUMENTS AND/OR PURCHASE RECEIPTS
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