Lucas County Substance Use Coalition Interest Form

1. What is your name?

2. What organization or agency do you represent? If you are not representing an organization or agency please put "community member".

3. What is your job title or role within your organization or agency? If you answered "community member" to question #2 you can leave this blank.

4. If you'd like to be added to the Lucas County Substance Use Coalition, please provide your email here: This question requires a valid email address.

5. Would you like to set up an introductory meeting with the Overdose Prevention Coordinator/Coalition lead?