New AMIAS (Al-Anon Member Involved in Alateen Service) Application Form Please enable JavaScript in your browser to complete this form.Please enable JavaScript in your browser to complete this form.APPLICANT INSTRUCTIONS Complete all fields. Initial each line item below; print your name, sign and date the form. Submit this form to your District Representative or District Alateen Liaison. Name *FirstLastEmail *Primary Phone *Address *Address Line 1City--- Select state ---AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingStateZip CodeI meet all SCWS Eligibility Requirements for AMIAS certification. I check each line item below as a true statement. *I am an Al-Anon member attending regular Al-Anon meetings, at least once a weekHome Meeting Location and City *Home Meeting Day and Time *Acceptance Criteria for AMIAS *I am at least 25 years of ageI have at least two consecutive years in Al-Anon in addition to any time spent in AlateenI have not been convicted of a felonyI have not been charged with child abuse or inappropriate sexual behaviorI have not demonstrated emotional problems which could result in harm to Alateen membersI am willing to step down immediately if there is a controversy that interferes with the purpose of serving Alateen membersI am in compliance with and agree to abide by the SCWS Area Alateen Safety and Behavioral Requirements I am willing to share my email address and phone number with other AMIAS. My preferred means of contact is:Text MessagePhone CallEmailCheck the method(s) of contact you prefer.I attended AMIAS Certification training (enter date and location) *Signature * Clear Signature Press and hold your mouse button to sign your name.Print your full nameIf the signature field is not working for you, type your name here.Date * Enter email location) Enter District email address to receive your form. *EmailConfirm EmailSubmit your form to your District Rep or DAL, they will complete submit the final form to the Alateen Area Process Person.CommentsSubmit
