Alumni Association Application

Contact Information

First Name

Last Name

Address

Address 2

City/Town

State/Province

ZIP/Postal Code

Home Phone

Work Phone

Cell Phone

Email Address

Additional Information

Birth Date*

Sobriety Date*

Employer

Occupation

Spouse or Significant Other's Name

Hobbies or Interests

Other Comments

Alumni Contacts

Our alumni contacts serve as vital resources to individuals who are new to the program of recovery. As an alumni contact, you would assist newly discharged patients in locating meetings and obtaining a sponsor in your community.

Would you like to be added to our alumni contact database?*

Yes