*Indicates a required field
 

SUBSTANCE ABUSE PREVENTION
EDUCATION / PROGRAM GRANT REQUEST

Print this form, complete it, and submit it to: Vivian Coeur
Alcohol and Other Drug Resource Center
Western Illinois University

*PROGRAM TITLE:

*LOCATION OF PROGRAM:

*PROGRAM DESCRIPTION:

Budget: (The starred fields must be filled in.)

Item Quantity Price Total
* * * *
     
     
     
     
     
     
     
     
     
     
     
     
     
     

*PROGRAM FORMAT: (At least one category must be checked.)

*TARGET AUDIENCE: (At least one category must be checked.)

*PUBLICITY: Describe the means by which the program will be promoted within the University community.



PROGRAM COORDINATOR:
*Name:
*Address:
*Phone:
*Email:

RESEARCH ASSISTANTS:
Name:
Name:
Name:
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