Philadelphia Area CoDA Intergroup

 Group Registration Form

Group Name:Group Meeting Place:

Street Address:

City:  State:   Zip Code:

Meeting Type: (Open, Closed, Step, Speaker, Etc.):

Other pertinent site information:

Day of Meeting:   Time of Meeting (From - To):

Have you registered your group with CoDA National?:Yes   No

Assigned Meeting Number, if already registered with CoDA National:

TELEPHONE CONTACT PERSON

Name:   Address:

City:   State:   Zip Code:

Telephone:   E-Mail Address:

By submitting this form, you are giving us permission to list your first name and last initial, phone number and e-mail address on both the web-based and mail-out meeting lists for the Philadelphia CoDA Intergroup.

MAIL CONTACT PERSON

SAME AS ABOVE? YES   NO

If NO, Please enter contact information below:

Name:   Address:

City:   State:   Zip Code:

Telephone:   E-Mail Address:

By submitting this form, you are agreeing to receive written communication for your meeting from within the Philadelphia CoDA Intergroup organization.

Note: Upon receipt of this completed form, we will contact the above-listed Contact Person(s) to verify the information and confirm the stated agreement/permission.