Group Name:
Contact Name  
First:
Last:
Address:
  (include apt/room/suite #)
City: State:
Zip Code:
Country:
   
Phone:
Email:
  type your complete email address:
ex.
your_name@aol.com, or name@yourdomain.com
an invalid email address may cause your submission to be lost.
   
Website:
  if your group does not have a website, type "none" in the space provided.
   
  Number of Women:
Number of Men:
  approximate or average numbers are fine if your membership is not consistent.
   
How old are the members in your group. Please select all that apply
Ages: Under 25
26-35
36-45
46-55
56-65
over 65
   
How long has your group been meeting?
  Less than 1 year
1-5 years
5-10 years
More than 10 years
   
Where do you meet?
 
  Please specify "Other"
 
   
How often do you meet? Please select all that apply
Weekly
Biweekly
Monthly
Bimonthly
Seasonally
Excluding summer months
Excluding December
Other
  Please specify "Other"
 
   
Please share any other information about your group that can assist Victoria with interacting with your group.