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Meeting Request Form

Area 45 Special Needs Committee

This form is provided for those who can’t get out due to health or other special circumstances and would like us to bring an AA meeting to them.

Please fill out this form, and click the submit button at the bottom

First name......................

Last Name or Initial......

Male/Female...................

Home group…...........…

Hometown……..........…

Email……............………

Phone…………..............-- Ext-

Describe your special situation:

Location Where you would like us to bring a meeting:

Name of person making this request: (Optional)

How can we best contact you?