The SANITY Support Group Network
Group Facilitator Registration Form

Email: GroupLeaders@SanitySupport.com
Web Site: www.SanitySupport.com

Personal Information

* First Name

* Last Name

* Street Address

Address Line 2

* City

* State

* Zip Code

* Phone Number

* Email Address

* Tell us why you want to start a SANITY Support Group.

Meeting Location Information

In the event you do not yet have the information to complete this form, please copy the fields (or print this page) and return here to register when you have the required information.

* Anticipated Group Meeting Start Date:

* Will your meetings be OPEN to the public to attend, or will they be CLOSED(private/invitation only)?

Open

Closed

* What day or day of the week will you meet?

* Meeting will start at:

*

AM

PM

* Meeting Location / Organization Name

* Address

* City

* ST

* Postal Code

* Phone

Church Pastor or Organization Owner/Manager/Supervisor

* First Name

* Last Name

* Street Address

Address Line 2

* City

* State

* Zip Code

* Phone Number

Email Address

If meetings will be listed on church/organization, or other web site, please give the specific page URL

References

Because we are dealing with such a sensitive topic, we’d like to communicate with someone who knows you. This could be a Pastor, Employer, Friend, or Co-Worker. Please let them know we may be calling them.

* Name

* Title / Relationship

* Phone

* Email Address

* Name

* Title /Relationship

* Phone

* Email Address

Additional Comments

Please send me a copy of this application

********FOR SSGN OFFICE USE ONLY ********

Group Code: _____ - ______

Group Name: SSGN-_______________________________________

If you would like a copy of this information for your records, please type your email address here:

* Indicates Response Required


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