PA Healthy Youth Coalition Member Survey

Volunteer Information

Question Title

* 1. Member Profile

First and Last Name *

Organization (if applicable)

Mailing Address *

Mailing Address 2

City/Town *

State *

Postal Code *

Email Address *

Phone Number *

Preferred Method of Contact

Question Title

* 2. Which of these community sectors or groups do you most closely relate to?

Business Community

Advocacy Volunteer

Mental Health

Public Health Professional

Emergency Medical Systems

Healthcare Professional

Pharmacy Professional

Law Enforcement / Public Safety

Court / Judiciary

Media

Parent / Caregiver

Religious or Fraternal Organization

Schools / Education

State, Local or Tribal Government

SUD Treatment

SUD Recovery Community

Youth

Youth-serving Organization

Military / Veteran

LGBTQ+ Supportive Organization

None of the above

Question Title

* 3. What is your job or role outside of PAHYC? (Select all that apply)

Parent or Guardian

Management

Educator

Owner

Coordinator

Specialist

Technician

Entry Level

Student

Volunteer

Retired

Intern

Other (please specify)