Name
Title
Organization
Address
City		State Zip Code
Phone		Fax
Email		Web Site

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Check one that best describes your organization

Human Services	Criminal Justice	Substance Abuse Program
Education Services	Faith Based Organization	Funding Organization
Corporate Community	Local Government Agency	Other

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I am interested in becoming a member of HTSAC
I am currently a member of HTSAC and would like to renew my membership

Please check the committees you already serve on or are interested in serving on:

Prevention	Treatment
Recovery	I cannot serve on a comittee but would like to be on the HTSAC mailing list

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In what areas of support can the Coalition assist your organization?

Evaluation	Needs Assessment	Resource Development
Funding	Research	Networking & Collaboration

May we include your information on our website? YES NO

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