Community Coalition Partnership Involvement Agreement

Together, we can create lasting change. Our coalition unites caring individuals, families, schools, and organizations to prevent substance use and promote mental well-being.

We use proven strategies that work—building a community where everyone feels supported and connected. Whether you’re a parent, teacher, student, or community member, there’s a place for you here.

Let’s make a positive impact and build a healthier community—together.

Examples of change include raising the age of access, increasing tobacco/alcohol taxes, passing social host ordinances, and promoting prescription drug take-back days.

Please choose the Community Coalition

Individual or

First NameLast Name

Organization Name

N/A if not part of an organization

Address:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Phone:

Format: (000) 000-0000.

Cell Phone:

Format: (000) 000-0000.

Email:

example@example.com

Preferred communication method:

Enter the community sector you represent.

I would like to be an active member in the following work groups: (Check all that apply)

Please indicate resources or services that you or your organization can provide for the Coalition: (Check all that apply)

Signature:

Date:

Date

Staff Signature:

Date:

Date

Expires August 31, 2029