Dothan-Houston County Substance Abuse Partnership
909 South St. Andrews
Dothan, AL  36301

If you have changed your mind.

Name:                                                                                      

Address:                                                                                             

City:                                                              Zip:                      

Phone:                                                                                       

School:                                                          Grade:                 

Do you work? Yes                                    No                   

List any schedule that may conflict with Youth Council meetings that are scheduled after school during the week (i.e. football, cheerleading, band practice)

I will be able to fulfill 20 community volunteer hours a month

          Yes                                       No              

I will be able to attend Saturday meetings

          Yes                                       No              

Signature