Safe Neighborhood Safe Homes

Please fill out the following form to receive 3 newsletters a year and to help register your neighborhood for the SNSH project.

Please provide the following contact information:

Name*

Neighborhood
or Apartment name*

Street Address

Address (cont.)

City*

Zip/Postal Code*

Phone Number

E-mail*

Select any of the following options that apply:

YES	Question
	I think youth access to alcohol is a big problem.
	I want to help do something about youth access to alcohol.
	Our neighborhood has family parties when alcohol is not served.
	I would like our neighborhood to have adult only parties when alcohol is served.
	??

Who lives with you?

Children ages 0-11

Children ages 12-18

Adults ages 19-21

Adults ages 22-30

Adults ages 31-up

Let us know what you think or do you have questions?

Name*
Neighborhood or Apartment name*
Street Address
Address (cont.)
City*
Zip/Postal Code*
Phone Number
E-mail*