MEETING REGISTRATION FORM
Date ___/___/___ c First time Registering
& Start Date ___/___/___ c Information Update & Meeting #________Please Note: In order for ACA WSO to be of maximum service the following information must be current, accurate and Complete. All information on this form will be used for ACA service purposes only.
MEETING INFORMATION
Country___________________________ Meeting Address: ____________________________________________________
City _________________________ County _______________State/Province ________________ Zip _________
Day _____________Time ________[AM] [PM] Group Name_________________________________________
Specific Meeting Location _______________________________________________________________________________
(Cross Streets, Building, Church, etc. For Example: Upstairs in back room in church at Allen & Del Mar)
Type- c Male, c Female, c Gay/Lesbian, c Beginners, c Open To All, c ACAs Only (Closed)
c Other
(please specify) ________________________________________________________________________Focus- c Discussion, c Speaker, c Steps, c Book Study, c Other ___________________________________
Notes- c Smoking, c Wheelchair Access, c Child Care, c Needs Support, c Other _____________________
Language ______________________, Other Comments or Info ________________________________________________
Intergroup Affiliation by Name or Number
: ______________________ phone-________________Public Contact: Please supply us with the following information to be used to assist people in finding your meeting.
Phone Contact; Name ________________________________ Phone ____________________________________
E-mail Contact; Name _______________________________ E-mail ____________________________________
Service Work Contact: The following Information is Confidential, for use within the ACA service structure only
Primary Contact Information
Position at meeting ________________________ First Name _________________Last Name ________________
Street / P.O. Box ______________________________________________________________________________
City _____________________________________State ____________________________ Zip_______________
Home Phone ( ) _______________ Alternate Phone ( ) ________________ e-mail ___________________
Secondary Contact Information or Meeting Mailing Address
Position at meeting ________________________ First Name _________________Last Name ________________
Street / P.O. Box ______________________________________________________________________________
City _____________________________________State ____________________________ Zip_______________
Home Phone ( ) _______________ Alternate Phone ( ) ________________ e-mail ___________________
Please list additional information
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