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Voting is Recovery Interest Form
First Name
*
Last Name
*
Email Address
Phone Number
*
*
Organization Name
*
What types of services does your organization primarily provide?
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Check all that apply
substance use disorder treatment & recovery services
mental health treatment & support services
interpersonal violence recovery & victim support services
harm reduction services
Something else
Your role at the organization
*
Your job title
*
Include a specific department/branch name if relevant
Organization Website
*
We'll feature the logo from this site.
State(s) served
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I'm signing up my organization to...
*
Select all that apply
Use Voter Registration materials during your Recovery Month activities
Use Voter Registration materials during your International Overdose Awareness Day activities
Host a voter registration event at your institution as part of Voting is Recovery
Host a competition across your staff/volunteers to see who can register the most voters
Something else
How did you hear about Voting is Recovery?
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Is there anything else we should know about you or your organization?
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Are you okay with your organization being listed as a
Civic Health Month Partner
?
Untitled multiple choice field
A
Yes
*
B
Not at this time
Submit