First Name(s):	

Last Name(s): 	

Best Telephone #: 	

Email Address: 	

   I/we will continue with my/our current group.

   I /we want to be part of a group but do not have one.

   I/we am/are willing to host a group in my home.

   I/we am/are willing to lead a group.

  Preferred day of the week is:   Mon  Tues  Wed  Thurs  Fri  Sat  Sun

  Preferred time of day is:           AM   PM