Page 1 of 1
First Name
*
Last Name
*
Email Address
Phone Number
*
*
Organization Name
*
What types of services does your organization primarily provide?
*
Check all that apply
What types of services does your organization primarily provide?
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
*
I'm signing up my organization to...
*
Select all that apply
I'm signing up my organization to...
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?
*
Is there anything else we should know about you or your organization?
*
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