Meeting AttendanceSite*-AWould 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?*Friend/FamilyTreatment ProviderProbation officerEmergency DepartmentFirst 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*MaleFemaleTransgenderOtherNonbinaryPrefer not to answerRace*WhiteHispanic, Latin, or Spanish OriginBlack or African AmericanMiddle Eastern or North AfricanAmerican Indian or Alaska NativeNative Hawaiian or Pacific IslanderAsianMore than one raceOtherWhat meeting type are you attending?*Alcoholics Anonymous, AANarcotics Anonymous, NASMART RecoveryAll RecoveryM.A.R.AAlanonFamilies AnonymousRefuge RecoveryOvereaters AnonymousMRE – Making Recovery EasyRaising kids in RecoverySeeking SafetyWRAPRecovery Coaching Meeting
