Join Us

East Haddam Local Prevention Council Membership Form 

EHLPC Logo 2012 Final
Thank you for your interest in being a part of East Haddam’s town‐wide effort to use the knowledge and resources of the
community to build a safe, healthy and drug free community to promote success for our youth.
 How can we contact you?
Name:  ___________________________________   Phone Number: _____________________________
Address: _____________________________________________________________________________
Email: ____________________________________  Agency/Organization: __________________ School/Grade: ______________________
What part of the community do you belong to?
___ Youth   ___ Parents  ___ Clergy  ___ Law Enforcement   ___ Business
___ Education  ___ Media  ___ Health Care    ___ Town Government
  ___ Civic/Volunteer Group   ___ Youth Serving  ___Other Substance Abuse Organization
What organization(s) do you belong to? What businesses are you associated with?  ______________________________________________________________________________________________________
As an EHLPC member, please check all skills/ideas that apply to you:
___Spreading Ideas        ___ Computer Skills        ___ Creativity/Artistic    ___ Motivating Others
___  Fundraising               ___ Data Collection/Analysis      ___ Photography             ___ Training
___ Web Design               ___ Public Speaking        ___ Event Volunteer      ___ Other: ________________
Commitment Level: Circle One
Gold: Leadership Member: Take a lead role in facilitating action plan and working with your team
Silver: Committee Member: Attend meetings and work with a group of members on a committee to drive an action plan items
Bronze Member: Help with individual events or tasks when available
 Please  return completed membership form to:
EHYFS; 387 East Haddam-Moodus Rd.  P.O. Box 572Moodus,  CT 06469
Or e-mail completed form to john.fournier@ehyfs.org

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