E-mail
*
example@example.com
Select a Meeting Date
December 3rd 2024 @ 9-11:30am
March 4th 2025 @9-11:30am
May 6th 2025 @ 9-11:30am
Full Name
*
First Name
Last Name
Job Title
Organization
Town of Employment
*
Town of Residence
*
Zipcode
*
Race / Ethnicity
*
American Indian / Alaska Native
Asian
Black / African American
Native Hawaiian / Other Pacific Islander
Multiracial
White
Prefer not to Respond
Hispanic / Latino Origin
*
Hispanic / Latino
Non-Hispanic / Latino
Prefer not to respond
Gender Identity
Male
Female
Non-binary
Prefer not to respond
Age
*
0-4
5-11
12-14
15-17
18-20
21-24
25-44
45-64
65+
Unknown
Service Population
*
Addiction Counselors
Adults
Business/Industry
Civic Group/Coalition
College Student
Community Member
Criminal Justice
Elementary School Student
EMT
Family Members
Firefighter
General Population
Healthcare Professionals
High School Student
Law Enforcement/Military
LGBTQIA+
Local Municipal Agency
Middle/Junior High School Students
Nurse (RN, LPN, CAN)
Nurse Practitioners
Parents/Families
Peer Recovery Support Positions
Pharmacists
Physician's Assistants
Physicians
Preschool Students
Prevention
Religious Groups
Social Workers
Teachers/Administrators/Counselors
Youth Services Organizations
Other
Prefer not to respond
Will you be joining us for breakfast and networking?
Yes
No
For our breakout focus session, please select you FIRST choice of topic:
Tobacco/Cannabis
Opioids
Alcohol
Other
If you select "other," please write your choice in below.
For our breakout focus session, please select your SECOND choice of topic:
Tobacco/Cannabis
Opioids
Alcohol
Other
If you select "other," please write your choice in below.
SUBMIT
Should be Empty: