East Haddam Local Prevention Council Membership Form
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: _____________________________
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 firstname.lastname@example.org