Community Member Registration

Contact Information

College/University Name

Name

Address

City

State

Zip

Phone

(xxx-xxx-xxxx)

Best Time to Contact

Email

Does your community have a campus/ community coalition?

If yes, are you involved?

Would you like information on organizing a coalition?

Does your community have a Court Monitoring program?

If yes, are you involved?

If no, would you like information on conducting Court Monitoring?

Does your community have a MADD affiliate?

If yes, are you involved?

If no, would you like information on volunteering for MADD?

Are you the parent of a college student?

If yes, what information would you be interested in receiving?

I am interested in receiving information on the following

	Alcohol purchase surveys
	Bring a Smart Car to Campus
	Campus Presentations on Drinking Problems and Solutions
	Campus/ Community Partnerships
	Candlelight Vigil
	Compliance Checks
	Court Monitoring
	Designated Driver Programs
	Law Enforcement Recognition
	Promote of Improve Campus Policies
	Promote or Improve Local Laws
	Reduce/eliminate alcohol advertising on campus
	Roll Call Briefings
	Sobriety Checkpoints
	Walk Like MADD

DRUNK DRIVING:
2.1 million students between the ages of 18 and 24 drove under the influence of alcohol last year (Hingson et al., 2002).