Signup Form

Welcome!

Print this form, complete the fields and mail it to the address indicated, or give it to the Treatment Facilities representative/chair/coordinator in your district.

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Bridging the Gap
Temporary Contact Information Sheet

Name: _______________________________________ Date: ________________

Address: ___________________________________________________________

Day Telephone: (_______) ________________ Circle Y if it's ok to leave a message

Eve. Telephone: (_______) ________________ Circle Y if it's ok to leave a message

(please circle your preferred phone number)

Cellphone: (________) _______________ E-mail: __________@_________________

Name of your Home Group: ______________________________________________

District? _____________

Sobriety Date _____________________ Gender: M F

Age: 15-20 20-25 25-35 35-55 over 55

Transportation available: Y N

If you live in the city, what areas are you willing to visit?

NE NW SE SW Central ALL

If you live rurally, please list other towns are you willing to visit:

Please return this form to your GSR, DCM or Central Office

Edmonton Central Office

Suite 206, 10010 - 107A - Avenue N.W.

Edmonton, AB T5H 4H8

Telephone 780.424.5900

Calgary Central Office

2, 4015 - 1 Street S.E.
(Access off 39th Avenue)
Calgary, Alberta T2G 4X7

Telephone: 403.777.1212

I AM RESPONSIBLE

WHEN ANYONE, ANYWHERE, REACHES OUT FOR HELP
I WANT THE HAND OF A.A. TO ALWAYS BE THERE,
AND FOR THAT….
I AM RESPONSIBLE