Intent of Membership Form - SAFE for Lake County

BECOME A MEMBER

First Name

Last Name

Title

Biography: (Positions you have held, why do you attend SAFE meetings, profession and educational background, what expertise do you bring to the SAFE, what community organizations have you volunteered for, what positions would you be willing to hold, etc.)

Name of agency, employer or N/A

Please provide a brief description of the agency and the services provided:

Address

City

Work Phone Number

Cell Phone Number

Please provide the name and email of two additional agency representatives:
Name

Name

Area of representation

Please indicate on which service committee(s) you prefer to serve:

MEMBERSHIP Seek out new members and help guide members into leadership positions PREVENTION Gathers info regarding skill, social and environmental change programs SUPPORT Services for those in recovery associated with addiction and substance abuse ACCOUNTABILITY Focusing with the legality and consequences of substance abuse COMPREHENSIVE COMMUNITY PLAN Gather data, community input, and help with annual report

BECOME A MEMBER

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