1. PEER EDUCATION GROUP STRUCTURE ( check the one which best describes your structure)

student activity club/organization
formal peer education group
associated with Greek organizations
associated with student government
part of a campus task force
student athlete group

2. OUR PRIMARY FOCUS IS...

alcohol abuse prevention
other drug prevention
health & safety issues for fraternities & sororities
sexual responsibility (STDs/HIV/AIDS)
sexual assault
diversity issues
other (indicate below)

3. CAMPUS ENVIRONMENT (please check one for each category)

Type of Institution:
Four year
Two year

Size of Campus:
Large (more than 12,000 students)
Medium (4001-12,000 students)
Small (4001 students or less)

Affiliation:
private
public/state

Population:
primarily commuter
primarily residential
half commuter/half residential

4. ADVISOR MAILING ADDRESS
It is crucial that we have a dependable and current advisor name and address for your group. If this information changes, contact us to update your files.

What is your group's current name?

College or University:

Advisor Name:

Advisor Title:

Advisor's Campus Mailing Address:

City, State, ZIP:

Office Phone:

Office Fax:

Advisor's Full E-mail Address:

Web Site Address:

5. HOW DID YOU FIND OUT ABOUT THE BACCHUS NETWORK™?

contact at an area conference
contact at another professional conference (indicate which one below)
       
contact with an area consultant or state coordinator
referral from another campus professional
attendance at General Assembly
referral from another campus student
contact with a national staff member
through review of our educational materials
web site

6. YOUR STUDENT LEADERS
Please list your current members and the various class years they represent within your group. Please designate one student who will correspond by e-mail with the area Student Advisory committee representatives. Attach an additional page if necessary.

Student Name 1 / Anticipated Year of Graduation:

Student Name 2 / Anticipated Year of Graduation:

Student Name 3 / Anticipated Year of Graduation:

Student Communication Correspondent:

E-mail Address:

Signature of Advisor: