Step 1 of 2 50% Organization NameName First Last Position TitleEmail* PhoneMailing Address Address Line 1 Address Line 2 City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Website URL Your OrganizationMy Organization is:*Click here to select.ProviderNon-profitGovernment AgencyOtherAre you active on social media? Please provide social media handles for Facebook, Twitter, InstagramPlease select any jurisdiction where your organization serves:*StatewideAllegany CountyAnne Arundel CountyBaltimore CityBaltimore CountyCalvert CountyCaroline CountyCarroll CountyCecil CountyCharles CountyDorchester CountyFrederick CountyGarrett CountyHarford CountyHoward CountyKent CountyMontgomery CountyPrince George’s CountyQueen Anne’s CountySaint Mary’s CountySomerset CountyTalbot CountyWashington CountyWicomico CountyWorcester CountyHow did you hear about the Campaign?Click here to select.Past participationColleague/co-workerSupervisorLocal school/school personnelDirectly from Children’s Mental Health Matters! CampaignHealth DepartmentMHAMDMCFOther OrganizationSocial MediaOtherNew this year:The Campaign will offer Event Kits for Community Champions (a Campaign poster, Campaign resources, giveaways and a green tablecloth) One is available per Community Champion, first come first serve. Kits will have one copy of each resource and we encourage you to make copies for your event as needed. Would you like to request an Event Kit for an event you are planning during/around Awareness Week?*YesNoPlease share your event details in space below so we can add to our Community Calendar:Which site will your pickup your Event Kit from:Click here to select pickup location.Baltimore City: MCF Baltimore Office, 2701 N. Charles Street, Ste. 400, Baltimore, MD 21218Carroll County: Carroll County Health Department, 290 South Center Street, Westminster, MD 21157Columbia: MCF Central Office, 10632 Little Patuxent Parkway, #234, Columbia, MD 21044Dundalk: MCF Dundalk Office, 1105 North Point Boulevard, Suite 325, Baltimore MarylandEastern Shore: MCF Caroline County Office, 9 South Third Street, Denton MD 21629Harford County: Harford County Department of Community Services, 125 N. Main Street, Bel Air, MD 21014Lutherville: MHAMD Office, Heaver Plaza, 1301 York Road, Ste. 505, Lutherville, MD 21093Montgomery County: EveryMind, 1000 Twinbrook Parkway, Rockville, MD 20851Prince George's County: Judy Hoyer Family Learning Center, Office of Psychological Services, 8908 Riggs Road, Adelphi, MDSalisbury: MCF Salisbury Office, 212 West Main Street, Suite 202B, Salisbury, MD 21801Waldorf: MCF Waldorf Office, 105 Paul Mellon Court, Waldorf, MD 20602Washington County: Jack E. Barr Center for Well-Being – San Mar Family & Community Services, 8504 Mapleville Road, Boonsboro, MD 21713I do not want an Event Kit for the 2020 Awareness Week. This iframe contains the logic required to handle Ajax powered Gravity Forms.