Contact Sheet
Tri-State Fibromyalgia & CFS Recovery

(To be filled out and returned at a Support Group Meeting
so we can keep you informed about news, changes in meetings, etc.)

PLEASE PRINT CLEARLY

NAME, ADDRESS, and PHONE NUMBER

Name ___________________________________________________________

Address__________________________________________________________

             __________________________________________________________

Phone Number ____________________________________________________

EMAIL ADDRESS

If you would like to be on the Group's Email List to get announcements about meetings
PLEASE PRINT EMAIL ADDRESS CLEARLY BELOW:

______________________________________________________________

I do not have an email address __________________

HOW DID YOU HEAR ABOUT US? (Check those that apply)

_____From my doctor (Please list his/her name) ______________________________________

_____From a brochure

_____From a newspaper (Which one?) _____________________________________________

_____From a friend

_____Other (Please explain) _____________________________________________________

SHARING YOUR CONTACT INFORMATION WITH OTHER GROUP MEMBERS
(In case someone needs a ride to the group)

____________ It is all right to give my name, phone number, and/or email to others who live near me

____________ Please do NOT give my name, phone number, and/or email to others who live near me