Please complete this form for your event.
Fields in
bold and red
are required.
Sponsoring Organization:
Contact Name:
First
Last
Adult
Youth
Event Address:
Apt / Suite
City/State/Zip:
Contact
Work:
Home:
Fax:
E-Mail
Preferred Contact:
Mail
Fax
E-Mail
Title of Event:
Zip Code:
Please describe the event:
Event time
The event will begin on :
Jan
Feb
Mar
Apr
May
Jun
Jul
Aug
Sep
Oct
Nov
Dec
1
2
3
4
5
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31
1999
2000
2001
2002
2003
2004
2005
1:00
1:30
2:00
2:30
3:00
3:30
4:00
4:30
5:00
5:30
6:00
6:30
7:00
7:30
8:00
8:30
9:00
9:30
10:00
10:30
11:00
11:30
12:00
12:30
AM
PM
and will end on:
Jan
Feb
Mar
Apr
May
Jun
Jul
Aug
Sep
Oct
Nov
Dec
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
1999
2000
2001
2002
2003
2004
2005
1:00
1:30
2:00
2:30
3:00
3:30
4:00
4:30
5:00
5:30
6:00
6:30
7:00
7:30
8:00
8:30
9:00
9:30
10:00
10:30
11:00
11:30
12:00
12:30
AM
PM
Audience:
Youth
Adults
Both
Which one of the following terms best describes this event?
Workshop
Conference
Committee or Task Force
Broadcast or Tele-Conference
Which is the primary Program Objective of Priority One will be addressed in this event?
(Please select only one.)
Increase the ability of parents and other adults to discourage drug use to our youth.
Increase the capacity for youth to influence other youth not to use drugs and to intervene in situations in which drug use is present.
Enhance the community's vigorous anti-drug media and public information campaigns.
Support and enhance school-based prevention programs.
Promote and support community-based prevention and intervention programs.
Disseminate information on the negative consequences of drug legalization for youth