Al-Anon Member Involved In Alateen Service

It is required that this form be completed by all Al-Anon members involved in service to Alateen.

(Please Print)

First & Last Name:

Street Address:

City, State/Province:

Zip/Postal Code/Phone

e-mail:

I am in compliance with my area's safety and behavioral requirements and agree to

abide by them.

Signature

Date

To the best of my knowledge, the above Al-Anon Member meets the area's safety

and behavioral requirements.

Authorized Area Signature

Area #

Date

Please Print Name Below:

Each area must certify to the WSO annually that each Al-Anon member involved in

Alateen service has met the area's safety and behavioral requirements and has

agreed to abide by them.

WSO assigned ID Number: 

TO BE FILLED OUT BY THE WTA ALATEEN COORDINATOR

TYPE OF CHECK VERIFIED

YES

NO

INITIAL

GROUP STATUS

DRIVER'S LICENSE INFORMATION

STATE BACKGROUND CHECK

As Area Alateen Coordinator, I certify that this person has met the WTA requirements for Teen Safety and has agreed

to abide by them.

Signature

Date

Phone #

Print Name

Title

District