[Participant Full Name]
[Date of Birth: MM/DD/YYYY]
[Street Address]
[City, State/Province, ZIP/Postal Code]
[Phone Number]
[Email Address]
Court / Agency Name: [Name of Court / Probation Department / Program]
Case / Docket Number: [Case Number]
Supervising Officer / Counselor: [Name, if applicable]
Phone / Email of Supervising Officer or Program: [Contact Information]
2. Meeting Requirement Summary
Total AA / NA Meetings Required: [Number]
Minimum Meetings per Week / Month (if applicable): [Requirement]
Program Start Date: [Date]
Program End Date / Review Date: [Date or “To Be Determined”]
3. Instructions for Participant
-
Bring this log to each AA / NA or similar support meeting.
-
Politely ask a group representative (such as the secretary, chairperson, or leader) to provide a signature or initials for verification.
-
Fill out all sections clearly and legibly in ink.
-
If additional pages are used, keep all pages together when submitting to court, probation, or your program.
Bring this log to each AA / NA or similar support meeting.
Politely ask a group representative (such as the secretary, chairperson, or leader) to provide a signature or initials for verification.
Fill out all sections clearly and legibly in ink.
If additional pages are used, keep all pages together when submitting to court, probation, or your program.
4. AA / NA Meeting Attendance Log
Meeting 1
Date: [MM/DD/YYYY]
Start Time: [Time]
End Time: [Time]
Type of Meeting: [AA / NA / Other]
Format: [In-Person / Online / Hybrid]
Group Name: [Name of Group]
Meeting Location / Online Platform: [Address or Online Platform/Link Description]
Group Representative Name (Print): [Name]
Group Representative Signature / Initials: [Signature / Initials]
Verification / Notes (optional): [Brief Notes]
Meeting 2
Meeting 3
Meeting 4
Meeting 5
Meeting 6
Meeting 7
Meeting 8
Meeting 9
Meeting 10
5. Participant Certification
I, [Participant Full Name], certify that the information recorded in this AA / NA Meeting Attendance Log is true and accurate to the best of my knowledge and that I attended the meetings listed above on the dates shown.
Participant Signature: [Signature]
Date: [Date]
6. Supervising Officer / Counselor Review (If Applicable)
Reviewed by: [Supervising Officer / Counselor Name]
Title / Agency: [Title / Agency Name]
Date of Review: [Date]
Signature: [Signature]