New Group Form

Does your group meet in a hospital, treatment center, jail or other institutional setting? *

Yes

No

If yes, is it open to regular AA members as well as patients or residents of the facility? *

Yes

No

Group Name *

Group Start Date *

Group Meeting Location *

Address *

City/Town *

Zip Code *

Meeting Day(s) *

Sunday

Monday

Tuesday

Wednesday

Thursday

Friday

Saturday

check all that apply

Meeting Type *

C-Closed

X-Step

F-French Speaking

S-Speaker

B-Big Book

H-Handicap Access

&-Spanish Speaking

D-Discussion

G-Gay/Lesbian

+-Hearing Impaired

*-Al-Anon same time & Place

check all that apply

Start Time *

End Time *

General Service Representative (GSR)

Name *

Phone *

Address *

City/Town *

State *

Zip *

Email *

Alternate GSR or Mail Contact

Name *

Phone *

Address *

City/Town *

State *

Zip *

Email *

Eastern States Directory

Ok to List in the Eastern States Directory for 12th Step Referral and/or requests for meeting information? *

Yes

No

NOTE: If “Yes,” the GSR’s (or other contact) full name and telephone # will be included with the group’s name and service number.

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