ACCR Getting Involved Form

Allegheny County
Coalition for Recovery

GETTING INVOLVED FORM

Name:
Address:
City, State & ZIP:
Phone:	Daytime: Evening:

May a message be left at the daytime phone number? Yes: No:
May a message be left at the evening phone number? Yes: No:

Email Address:

Interests (Please check all that apply):

Volunteering to work at an ACCR event

Serve on the ACCR committee indicated below

Child and Family	Education	Public Awareness	Quality Improvement
Consumer/Provider	Web Site

Please fill in this form and press the submit button
or print out the form, fill it out and send it through the U.S. Mail to:
ACCR c/o PSAN 938 Penn Avenue Pittsburgh, PA 15222	Thank You