Become a Hanley Center Alumni Ambassador

I have at least 1 year of continuous Recovery. I give Hanley Center permission to use the information I have provided on this form in order to contact me as I am willing to serve as an Alumni Ambassador for Hanley Aumni returning to my home area.

By completing and submitting this form, I give my permission to be contacted by the Hanley Center staff or Hanley Center volunteers. I am also authorizing a Hanley Center employee or volunteer to give my first name, last initial and telephone number to Hanley Alumni returning to my home area.

* is required
Program of Interest*	Men's Women's Older Adults (55+) Outpatient Family
Male/Female (select)*	Male Female
Date of Discharge from Hanley*
Date of Sobriety*
Date of birth*
First Name*
Last Name*
Mailing Address*
Mailing Address 2
City*
State*
Zip*
Country*
Home phone*
Cell phone
Email Address*
I attend meetings and can be a contact for:  AA   NA   Alanon   Alateen
Yes, I have a sponsor
The group I attend most frequently is:
Name of Group
Meeting Location
Meeting Day
Meeting Time
Additional Comments: