Name of Person Registering:

Phone (Optional):

Email Address:

Organization:

Address:

City:

State: County: Zip:

Which best describes your professional affiliation?: Education Emergency Medical Response Law Enforcement Other Medical Professional Other Prosecution Social Work

Are you currently involved with DEC efforts in your community?: Yes No

Please describe your role in the organization of this effort :

Who is the lead contact for your Community DEC Team? :

Lead Contact Name:
Lead Contact Address:
Lead Contact Email:
Team Website:

Is this a Local or Regional effort: Local Regional

Does the team have additional operational funds : Yes No

Is the DEC team part of an existing community coalition? : UNITE ASAP Children's Champion Other