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Addiction Loss Group Night Registration

Please fill out the form below if you plan on attending this month’s Addiction Loss group night.

Tuesday, October 11, 2022 @ 6:30 PM

In Person

Addiction Loss Group Night Registration

Please fill out the form below if you are planning on attending this month's Addiction Loss Group Night. Due to rising COVID numbers, we appreciate knowing beforehand how many attendees we can expect.

Today's Date*
MM slash DD slash YYYY
Name*
First Last
Phone*
Email*
COVID-19*
I agree that I will not attend group if anyone in my party has been experiencing COVID-like symptoms or has received a positive COVID test in the last 14 days.
Masks Required*
I understand that masks are required at group night, regardless of vaccination status. I agree to wear a mask at group night, unless instructed otherwise by a Heartlinks counselor.
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