Contact Information:

• Last name:
  First name:
  M.I.:

• Address:
  
• State:
  AK AL AR AZ CA CO CT DC DE FL GA HI IA ID IL IN KS KY LA MA MD ME MI MN MO MS MT NC ND NE NH NJ NM NV NY OH OK OR PA RI SC SD TN TX UT VA VT WA WI WV WY
• City:
  Zip Code:

• School name:
  
• Phone:
  
• E-mail:
  
• Grade Levels:
  # of Students:

Prevention History:

• Has your school ever had a drug prevention program?
  yes
  no
• If so, what kind of program ?
  
• Was it a fee-for-service or a free-of-charge program ?
  fee-for-service
  free-of-charge
• What effect did this program have ?
  
• Were you satisfied with the outcome of the program?
  yes
  no
• Does your school have any alcohol/drug-related problems that you are aware of?
  yes
  no
• If yes, please describe them:
  

Other Information:

• Does your school want more presentations about drugs/alcohol ?
  yes
  no
• Please describe briefly what is going on with your school right now. Also add any other information that we should know (best time to call, etc):