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2026 Youth Prevention Institute Registration
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2026 Youth Prevention Summit: IN-REGION
Name
(Required)
First
Last
Job Title or Role
(Required)
Credentials
Name as you would like it to appear on your nametag:
(Required)
Name as you would like it to appear on your certificate for continuing education:
(Required)
Email Address
(Required)
Daytime Phone Number
Mailing Address
(Required)
Street Address
Address Line 2
City
Alabama
Alaska
American Samoa
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Guam
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Northern Mariana Islands
Ohio
Oklahoma
Oregon
Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
U.S. Virgin Islands
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
State
ZIP Code
County Where You Work
(Required)
Mailing Address
How many years have you worked in primary prevention?
(Required)
0-1 Years
2-3 Years
4-5 Years
6-10 Years
More than 10 Years
I do not work in primary prevention
Are you, or have you ever been, certified as a Prevention Specialist, Prevention Professional, or other prevention-related certification?
(Required)
Never certified
Never certified, but working towards certification
Previously certified, but not now
Currently certified
What is your job responsibility? (check all that apply)
(Required)
Program staff
Supervisor of program staff
Administrator
Educator
Social Worker
Coalition Director/Coordinator
Law enforcement
Other
Other Job Responsibility (specify):
(Required)
What is your primary work setting or profession/discipline?
(Required)
Community coalition
Education (K-12)
Higher education
Non-profit/community-based organization
Faith-based organization
Law enforcement or criminal justice, corrections
Community health
Primary care or other medical setting
Independent consultant/provider
Local government
County government
State/Jurisdiction government
Federal government
Tribal government
Business
Military/VA
Other
Check any organization(s) you are affiliated with from the list below:
(Required)
HIDTA staff
Overdose Response Strategy
National Guard
DFC-funded organization
Non-DFC coalition
Other
None of the above
Other Organization Affiliation (specify)
(Required)
If you are affiliated with a HIDTA, which of these HIDTA roles best describes your position?
HIDTA Director
HIDTA Deputy Director
HIDTA Prevention Coordinator
ORS PHA
ORS DIO
NG Counterdrug
No HIDTA affiliation
Other
What is your organization’s primary focus?
(Required)
Substance misuse prevention
Substance misuse treatment
Mental health promotion
Mental health treatment
Violence prevention
Criminal justice
Education—K-12
Education—Higher Education
Research
Military
Healthcare
Faith community
Government
Social/Human Services
Other
Which of the following SAMHSA Grant Programs do you currently have? (Select all that apply)
(Required)
Strategic Prevention Framework - Partnerships for Success (SPF-PFS)
Substance Abuse and HIV Prevention Navigator Programs for Racial/Ethnic Minorities (Prevention Navigator)
Sober Truth on Preventing (STOP) Underage Drinking Act Grant Program
Prevent Prescription Drug/Opioid Overdose-Related Deaths (PDO)
First Responders Comprehensive Addiction and Recovery Act (FR-CARA)
Strategic Prevention Framework for Prescription Drugs (SPF-Rx)
Improving Access to Overdose Treatment (OD Tx)
SUPTRS Block Grant (direct or sub-recipient)
No SAMHSA funding currently
Don’t know/Not sure
Other
Other SAMHSA Grant (specify)
(Required)
How IMPORTANT to you is enhancing your ability to build health-promoting relationships?
(Required)
Extremely
Very
Moderately
Slightly
Not at all
How READY are you to enhance your ability to build health-promoting relationships with youth?
(Required)
Extremely
Very
Moderately
Slightly
Not at all
In what ways would you like to grow in your ability to build health-promoting relationships with youth?
(Required)
