SAPCA Membership Form

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Mission: To engage diverse sectors of the community in collaborative, cross-cultural and comprehensive substance abuse prevention efforts that result in a reduction of underage substance use and abuse in the City of Alexandria.

Goals: (1) Establish and strengthen collaboration among communities, nonprofit agencies, and federal, state, local, and tribal governments to support the efforts of community coalitions to prevent and reduce substance use among youth. (2) Reduce substance abuse among youth and, over time, among adults by addressing the factors in a community that increase the risk of substance abuse and promoting the factors that minimize the risk of substance abuse.

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* 1. First and Last Name

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* 2. Today's Date

Date / Time

Date

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* 3. E-mail

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* 4. Phone number

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* 5. Mailing address

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* 6. How did you hear about us?

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* 7. Mark the ONE category that best describes the area you represent:

Youth

Parent

Health Organization

Business

Government

Schools

Media

Other Organization involved in reducing substance abuse

Law Enforcement

Faith-Based

Civic/Volunteer Group

Youth Serving Organization

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* 8. Areas of Interest:

Strategic Planning

Evaluation

Community Outreach

Communications/Marketing

Fund Development/Sustainability

Other (please specify)

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* 9. About You! (Experience in substance abuse prevention field, educational background, community affiliations, special interests and accomplishments):

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* 10. I agree to serve as an active member of the Substance Abuse Prevention Coalition of Alexandria.

As an active member of SAPCA, I agree to help SAPCA by doing one or more of the following:

-Involving youth in decision making, discussions and programming
-Working to create opportunities for youth development 
-Serving as an advocate and partner for SAPCA and its policies 
-Participating in one of SAPCA’s Workgroups

Name:

Date:

Substance Abuse Prevention Coalition of Alexandria Board Member Application

(Complete only if you are a nominee for the Board)

SAPCA Membership Form

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* 1. First and Last Name

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* 2. Today's Date

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* 3. E-mail

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* 4. Phone number

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* 5. Mailing address

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* 6. How did you hear about us?

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* 7. Mark the ONE category that best describes the area you represent:

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* 8. Areas of Interest:

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* 9. About You! (Experience in substance abuse prevention field, educational background, community affiliations, special interests and accomplishments):

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* 11. Why do you want to serve on SAPCA's Board?

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* 12. Please provide a 1-2 paragraph biography of yourself to be printed in the SAPCA Board Election Ballot.