Forms for Coordinators to Complete Regularly
About My A.W.A.K.E. Group
Date_______________________
Coordinator______________________________________________________
Contact person for group (if different than coordinator)_____________________________________________
Phone for contact person (if different than coordinator)______________________________________________
Coordinator's Address______________________________________________________
________________________________________________________________
City________________________________________State_________________Zip________
Phone (Day)_________________________________(Eve)__________________________________
Fax________________________________E-mail_________________________________
Name of Group (e.g., Elk Grove Village A.W.A.K.E.)_________________________________________
First Meeting Scheduled for (date) _________________________________________________
Where We Meet__________________________________________________________________
How Often? ________________________________________How Many Usually Attend?_________
Group Sponsor/s_____________________________________________________
___________________________________________________________________
Group Structure:
___Coordinator and informal volunteers
___Coordinator and committees or elected officers
___Representative of sponsor is interim leader while continuing to search for patient coordinator
___Other_________________________________________________________