Norfolk Prevention Coalition Involvement Agreement

Coalition Involvement Agreement

This agreement between Norfolk Prevention Coalition and the Sector Representative. It shall be from the start date indicated in this agreement until terminated by a mutual accord. This agreement will be reevaluated on a yearly basis.

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* 1. Last Name

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* 2. First Name

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* 3. Middle Initial

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* 4. Suffix

Sr.

Jr.

III.

IV.

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* 5. Email Address

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* 6. Phone Number

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* 7. Mailing Address

Street

Unit

City

State

Zip

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* 8. What is the name of the Family/Organization that you represent?

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* 9. What is your title within this Family/Organization?

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* 10. Within what Community Sector is your Family/Organization providing services and or products?

Youths - Individuals who are 18 years of age or younger

Parents - Individuals legally responsible for a child, grandchild or foster child

Business - A representative of a business-related organization

Media - A representative of a communication outlet that provides information to the community

School - A representative of the school system with influence in school policies and procedures

Youth-Serving Organization - A representative of an organization that provides services to youth

Law Enforcement - A representative of a law enforcement agency. The representative must be a sworn law enforcement officer.

Religious/Fraternal Organization - A representative of a faith-based organization. The representative’s role must be of a leader, not a member.

Civic/Volunteer Group - A representative of an organization that provides civic or volunteer activities to the community (not a coalition member)

Healthcare Professional - An individual legally allowed to provide physical, mental, or behavioral healthcare services

State, Local or Tribal Governmental Agency with Expertise in the Field of Substance Abuse - A representative of a government-funded agency with a focus on substance abuse

Other Organization Involved in Reducing Substance Abuse - A community organization that addresses substance abuse

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* 11. On a scale from 1-5, with 5 being the highest and 1 being the lowest, please rate the level of importance on the responsibilities of Norfolk Prevention Coalition to your family/organization/community.

	1	2	3	4	5
Creating and following by-laws and policies.	Creating and following by-laws and policies. 1	Creating and following by-laws and policies. 2	Creating and following by-laws and policies. 3	Creating and following by-laws and policies. 4	Creating and following by-laws and policies. 5
Formulating coalition goals and objectives.	Formulating coalition goals and objectives. 1	Formulating coalition goals and objectives. 2	Formulating coalition goals and objectives. 3	Formulating coalition goals and objectives. 4	Formulating coalition goals and objectives. 5
Overseeing operations of activities, programs, and paid staff.	Overseeing operations of activities, programs, and paid staff. 1	Overseeing operations of activities, programs, and paid staff. 2	Overseeing operations of activities, programs, and paid staff. 3	Overseeing operations of activities, programs, and paid staff. 4	Overseeing operations of activities, programs, and paid staff. 5
Increasing new membership of the coalition.	Increasing new membership of the coalition. 1	Increasing new membership of the coalition. 2	Increasing new membership of the coalition. 3	Increasing new membership of the coalition. 4	Increasing new membership of the coalition. 5
Facilitating the creation and follow through of a strategic Action Plan.	Facilitating the creation and follow through of a strategic Action Plan. 1	Facilitating the creation and follow through of a strategic Action Plan. 2	Facilitating the creation and follow through of a strategic Action Plan. 3	Facilitating the creation and follow through of a strategic Action Plan. 4	Facilitating the creation and follow through of a strategic Action Plan. 5
Creating a credible and relevant sustainability plan which includes volunteer membership and resources, both financial and material.	Creating a credible and relevant sustainability plan which includes volunteer membership and resources, both financial and material. 1	Creating a credible and relevant sustainability plan which includes volunteer membership and resources, both financial and material. 2	Creating a credible and relevant sustainability plan which includes volunteer membership and resources, both financial and material. 3	Creating a credible and relevant sustainability plan which includes volunteer membership and resources, both financial and material. 4	Creating a credible and relevant sustainability plan which includes volunteer membership and resources, both financial and material. 5
Respecting the rights of Norfolk Prevention Coalition members to hold their own opinions and beliefs.	Respecting the rights of Norfolk Prevention Coalition members to hold their own opinions and beliefs. 1	Respecting the rights of Norfolk Prevention Coalition members to hold their own opinions and beliefs. 2	Respecting the rights of Norfolk Prevention Coalition members to hold their own opinions and beliefs. 3	Respecting the rights of Norfolk Prevention Coalition members to hold their own opinions and beliefs. 4	Respecting the rights of Norfolk Prevention Coalition members to hold their own opinions and beliefs. 5

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* 12. On a scale from 1-5, with 5 being the highest and 1 being the lowest, please rate the level of importance on your responsibilities to Norfolk Prevention Coalition.

	1	2	3	4	5
Being a community leader amongst the represented sector.	Being a community leader amongst the represented sector. 1	Being a community leader amongst the represented sector. 2	Being a community leader amongst the represented sector. 3	Being a community leader amongst the represented sector. 4	Being a community leader amongst the represented sector. 5
Ensuring clear communication between the sector represented and the coalition.	Ensuring clear communication between the sector represented and the coalition. 1	Ensuring clear communication between the sector represented and the coalition. 2	Ensuring clear communication between the sector represented and the coalition. 3	Ensuring clear communication between the sector represented and the coalition. 4	Ensuring clear communication between the sector represented and the coalition. 5
Acting as a positive role model for youth, families, and peers.	Acting as a positive role model for youth, families, and peers. 1	Acting as a positive role model for youth, families, and peers. 2	Acting as a positive role model for youth, families, and peers. 3	Acting as a positive role model for youth, families, and peers. 4	Acting as a positive role model for youth, families, and peers. 5
Supporting the coalition’s mission.	Supporting the coalition’s mission. 1	Supporting the coalition’s mission. 2	Supporting the coalition’s mission. 3	Supporting the coalition’s mission. 4	Supporting the coalition’s mission. 5
Attending monthly coalition meetings.	Attending monthly coalition meetings. 1	Attending monthly coalition meetings. 2	Attending monthly coalition meetings. 3	Attending monthly coalition meetings. 4	Attending monthly coalition meetings. 5
Participating in at least one subcommittee.	Participating in at least one subcommittee. 1	Participating in at least one subcommittee. 2	Participating in at least one subcommittee. 3	Participating in at least one subcommittee. 4	Participating in at least one subcommittee. 5
Attending coalition sponsored trainings, town hall meetings, and community events.	Attending coalition sponsored trainings, town hall meetings, and community events. 1	Attending coalition sponsored trainings, town hall meetings, and community events. 2	Attending coalition sponsored trainings, town hall meetings, and community events. 3	Attending coalition sponsored trainings, town hall meetings, and community events. 4	Attending coalition sponsored trainings, town hall meetings, and community events. 5
Contributing to the strategic planning process.	Contributing to the strategic planning process. 1	Contributing to the strategic planning process. 2	Contributing to the strategic planning process. 3	Contributing to the strategic planning process. 4	Contributing to the strategic planning process. 5
Participating in sustaining the coalition’s capacity, involvement, and goals.	Participating in sustaining the coalition’s capacity, involvement, and goals. 1	Participating in sustaining the coalition’s capacity, involvement, and goals. 2	Participating in sustaining the coalition’s capacity, involvement, and goals. 3	Participating in sustaining the coalition’s capacity, involvement, and goals. 4	Participating in sustaining the coalition’s capacity, involvement, and goals. 5
Participating in the Drug Free Coalition (DFC) Workstation, a communication vehicle used by DFC to provide timely information to coalitions.	Participating in the Drug Free Coalition (DFC) Workstation, a communication vehicle used by DFC to provide timely information to coalitions. 1	Participating in the Drug Free Coalition (DFC) Workstation, a communication vehicle used by DFC to provide timely information to coalitions. 2	Participating in the Drug Free Coalition (DFC) Workstation, a communication vehicle used by DFC to provide timely information to coalitions. 3	Participating in the Drug Free Coalition (DFC) Workstation, a communication vehicle used by DFC to provide timely information to coalitions. 4	Participating in the Drug Free Coalition (DFC) Workstation, a communication vehicle used by DFC to provide timely information to coalitions. 5
Preventing youth substance use through environmental strategies.	Preventing youth substance use through environmental strategies. 1	Preventing youth substance use through environmental strategies. 2	Preventing youth substance use through environmental strategies. 3	Preventing youth substance use through environmental strategies. 4	Preventing youth substance use through environmental strategies. 5
Using your activities as in-kind services match, if applicable.	Using your activities as in-kind services match, if applicable. 1	Using your activities as in-kind services match, if applicable. 2	Using your activities as in-kind services match, if applicable. 3	Using your activities as in-kind services match, if applicable. 4	Using your activities as in-kind services match, if applicable. 5

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* 13. If you agree that you will be responsible for the 12 general functions listed in question 9, please use the text boxes, below, to sign this agreement and notify its initiators.

Your Community Sector

Your Full Name

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* 14. This agreement between Norfolk Prevention Coalition and (You) as a Representative of (Your) Community Sector, shall be from [Start Date_________] until terminated by a mutual accord. This agreement will be reevaluated on a yearly basis.

Start Date of Your Service to NPC (most likely today's date)

Norfolk Prevention Coalition Involvement Agreement

Coalition Involvement Agreement

Question Title

* 1. Last Name

Question Title

* 2. First Name

Question Title

* 3. Middle Initial

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* 4. Suffix

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* 5. Email Address

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* 6. Phone Number

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* 7. Mailing Address

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* 8. What is the name of the Family/Organization that you represent?

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* 9. What is your title within this Family/Organization?

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* 10. Within what Community Sector is your Family/Organization providing services and or products?

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* 11. On a scale from 1-5, with 5 being the highest and 1 being the lowest, please rate the level of importance on the responsibilities of Norfolk Prevention Coalition to your family/organization/community.

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* 12. On a scale from 1-5, with 5 being the highest and 1 being the lowest, please rate the level of importance on your responsibilities to Norfolk Prevention Coalition.

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* 13. If you agree that you will be responsible for the 12 general functions listed in question 9, please use the text boxes, below, to sign this agreement and notify its initiators.

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* 14. This agreement between Norfolk Prevention Coalition and (You) as a Representative of (Your) Community Sector, shall be from [Start Date_________] until terminated by a mutual accord. This agreement will be reevaluated on a yearly basis.

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* 15. By entering your full name below, you are adopting this typed text to represent your consent to authorize this Coalition Involvement Agreement.