Community Contact Form and Agreement

Community Contact

ACT Missouri requires each Youth Ambassador to have a community contact who is at least 21 years old, passionate about substance use prevention, and committed to living a healthy lifestyle. Community contacts may be a teacher, counselor, coach, pastor, mentor, etc. Community contacts will support the student in his or her efforts to develop leadership and advocacy skills. Upon returning from training, the Youth Ambassador may call on the community contact to help plan and promote community service and substance-free activities. Community contacts are welcome to attend trainings and activities with the Youth Ambassador.

Name*
First Last
Youth Ambassador Name*
First Last
School, Coalition, or Organization Name*
School, Coalition, or Organization Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code
Work Phone*
Home or Cell Phone*
Project Director may send occasional text messages
Email*
Relationship to Applicant*
Community Contact Agreement
I have reviewed and understand my role as a community contact. *Note: Initialing below serves in the same capacity as your personal signature.
Initials*
Date*
MM slash DD slash YYYY

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Community Contact Form and Agreement

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Community Contact Agreement

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