Step One:  Record the name of your local alliance.

Local Alliance Name:

Step Two: Record the following information about your Local Alliance’s Key Contact:
Note: Items marked * are required.

Name:*

Organization:

Address:

City:

Zip Code:

County:

Daytime Phone:

Fax:

Email Address:*

Step Three: Answer the following narrative questions.

1. When was your local alliance established? Please indicate month and year.
   
2. What is the mission of your local alliance?
   
3. What are the goals, objectives and main activities of your local alliance?
     
4. How do youth and adults work together within your local alliance?
    
5. Are the activities of your local alliance funded or staffed?  If yes, how?
   
6. What community sectors do members of your local alliance represent? In order for your application to be accepted, at least five (5) different groups must be represented. Check all that apply.

Youth
Parents
Business Community
Media
Schools
Youth-Serving Organizations
Religious or Fraternal Organizations
Law Enforcement
Civic & Volunteer Groups
Healthcare Professionals, including mental health and substance abuse
State, Local and/or tribal government agencies
Other organizations involved in reducing substance abuse

7. How often does your local alliance meet?
   
8. Please include meeting dates of the past 12 months
   
9. Please submit meeting minutes from a recent meeting by email to info@allwisyouth.org. In addition, please submit a list of members and their agency affiliations with OPTIONAL email address.  If you provide email addresses, we will email Alliance information, announcements, research updates and other resources directly to your members as well as to your Key Contact.