Group Registration Form

Groups are registered with the World Service Office (WSO) with the understanding
that they will abide by all the Co-Anon Family Group Traditions
and have no outside affiliations.

The following information below will help us keep our records up to date.
Please fill out and submit the form as complete as possible.
Please notify the World Service Office of all changes as they occur.

Thank you,
Co-Anon World Service Board

DATE GROUP STARTED *

GROUP NAME *

HELD ON WHAT DAY / TIME *
Please enter the day of the week and starting time

BUILDING or LOCATION NAME *

Address *
Address Line 1
Address Line 2
City
State / Province / Region
Zip / Postal Code
Country

Primary Group Contact Info

Primary Name and Initial *

Primary Email *

Primary Phone

Group Secretary

Secretary Name and Initial

Secretary Email

Secretary Phone

Group Treasurer

Treasurer Name and Initial

Treasurer Email

Treasurer Phone

Group Service Representative

GSR First Name and Initial

GSR Email

GSR Phone

Alternate Group Service Representative

ALT GSR First Name and Initial

ALT GSR Email

ALT GSR Phone

The opportunity to be of service
We need a few people from each group who are willing to have their first names
and phone numbers listed with the office. Newcomers and referrals from the helpline
often need directions to a meeting in your area. Thank you for carrying the message
of hope to those that are seeking help.

12 STEP CONTACT

12Step Volunteer Name and Initial

12Step Volunteer Phone

12 STEP CONTACT

12Step Volunteer 2 First Name and Initial

12Step Volunteer 2 Phone

Name