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Consent to Serve as a Convener
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First and Last Name
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Address
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Preferred Phone Number
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Email
Your answer
Please answer the following questions
Why do you want to be a Peer Support Convener?
Your answer
Are you a member of any community-based support groups such as AA or NA? Please list:
Your answer
What is your sobriety date?
MM
/
DD
/
YYYY
What is your total time in recovery?
Your answer
What skills do you possess that will assist you in working as a convener?
Your answer
Are you able to commit to attending up to two (2) meetings per month and an annual
convener meeting?
Yes
No
Clear selection
Are you committed to support and an abstinence-based recovery program?
Yes
No
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Education:
Your answer
Professional Experience:
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Volunteer Experience (include offices held)
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Are you or has someone close to you been affected by substance use disorder?
Your answer
Please type your name and today's date below as your signature.
If accepted as a convener, I promise to serve to the best of my ability in the best interest of nurses and the Nursing Peer Support Network.
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