Meeting AttendanceWould you like to remain anonymous?*YesNoAre 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* 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 meeting type are you attending?*AA MeetingCAA MeetingRecovery DharmaFamily Fun NightCrystal Meth AnonymousSMART RecoveryRecovery Leadership Initiative CourseCoffee & RecoveryDouble Trouble Recovery MeetingCrystal Meth AnonymousYoung People in RecoverySeeking SafetyLifeRing/Secular RecoveryMARS Support GroupRecovery Advocacy TrainingVeterans Recovery Support GroupRecovery ChampsOxford HouseKinship/Family Support GroupOther: (write in)Other Meeting Type*
