Activity Check-inAre you an existing member?*YesNoPlease enter your participant short code*Your participant short code is your first initial, last initial, birth day, month and year in the following format: FL01021901 Where First Last's birth date is 2/1/1901.How did you hear about us?*TreatmentHealthCareCriminal Justice SystemFocus RWC PeerCommunity AgencyFriend/FamilyFirst Name*Last Name*Phone*If you don't have a current phone number, please input "No phone".Email* If you don't have an email address, please input "no@email.com".Address* Street Address 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 Birth Date* Date Format: MM slash DD slash YYYY Gender*FemaleMaleTransgenderOtherNonbinaryPrefer not to answerRace*American Indian or Alaska NativeAsianBlack or African AmericanHispanic, Latin, or Spanish OriginMiddle Eastern or North AfricanNative Hawaiian or Pacific IslanderMore than one raceWhiteOtherWhat event/activity are you attending?*Community Service ProjectRecovery ActivityRCO EventFamily Fun Night
