Membership Form

Name

Yes, include my name on a list that will be printed and circulated to members.

Mailing Address

City

State

Zip

Include address in the printed directory Yes No

Email Address

Include email in the printed directory Yes No

Work Phone

Include work phone in the printed directory Yes No

Fax Number

Include fax number in the printed directory Yes No

May we call you to help another social worker in your area?

Yes No

May we email you to help another social worker in your area?

Yes No

Can you speak freely at home?

Yes No

Can you speak freely at work?

Yes No

How did you find out about SWHSW?

Approximately how long have you been in a 12-step program?

What 12-step fellowships do you participate in?

NEED A TERMS OF AGREEMENT STATEMENT FOR HERE.

Please enter the word you see in the image below: