Registration Agreement

Registration Agreement

I want to volunteer to help the National Council on Alcoholism and Drug Dependence, Inc. (NCADD) reduce the stigma associated with alcoholism and other drug addictions. I have at least two years in recovery, and am willing to discuss my recovery without compromising the anonymity tradition that is part of most twelve-step programs.

Yes! *

Your Details

First Name * Last Name *

Address * City * State * Zip Code

Telephone Number * Fax Number

e-mail address *

Recovery Details

Gender * Date of Birth * Ethnic Background * Profession *

Single Married Domestic Partner Divorced Children

What Month and year did you begin your recovery? * What drugs did you use? * Please tell us about your alcoholism/addiction, how your recovery began, the benefits of life in recovery and your work in helping others: *

Thank you for your submission, we will contact you within 5 business days.

If you do not hear from us please re-submit or contact us.

regards

NCADD