Volunteer

Get Involved with CNVRAC Today!

Contact Information

Name *

Please enter your full name.

Address *

Please enter your full address.

Phone *

Please enter your contact phone number in the following format: XXX-XXX-XXXX.

Email *

Please enter your email address.

Other Information

School *

Enter the name of the school you attend.

Grade *

Enter your grade.

Emergency Contact *

Enter the NAME and NUMBER of the person to call in the event of an emergency.

Allergies/Medical Concerns

Let us know if you have any medical issues we would be aware of.

Parent/Guardian Information

Name of Parent or Guardian

Enter the full name of a parent of guardian (if under 18 years old).

Phone Number for Parent or Guardian

Enter the phone number for a parent of guardian (if under 18 years old).

Questionnaire

Would you like to be part of a council that will allow you to make a difference? Tell us why? *

What can you contribute to help prevent substance abuse? *

Summarize special skills and qualifications you have from previous volunteer work, employment, or through other activities including hobbies and sports? *

Councils and Committees

I would like to be involved in the (check all that apply):

Steering Committee – governs the day to day work of the CNVRAC

Prevention Committee – Convenes area prevention professionals to share resources, identify prevention priorities, & to network with colleagues in the field

Local Prevention Council – Town level volunteer prevention advocates who work together to promote wellness and address local-level substance abuse prevention needs

Youth Action Council – Youth groups across service area who work together to address issues affecting peers

For more information, please contact: Jesse Mancinone, Prevention Coordinator 203-578-4044 or you may email him at cnvracprevention@sbcglobal.net or send this form to: CNVRAC, 22 Chase River Road, Waterbury, CT 06704; Fax: 203-756-6032

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