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    Rick Lepkowski completed a volunteer speaker questionnaire for the N.Y. Inter-Group office. He provided his contact information and indicated availability to speak to various groups including junior high, senior high, college, and graduate students as well as religious, civic, business, and senior citizen groups. Lepkowski has been sober since 1988 and is over 60 years old. He is available most days of the week in the evenings and can provide his own transportation.

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    Public Information Volunteer Form (AA)

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    4-PI-Volunter-Sign-Up-Form

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    Rick Lepkowski completed a volunteer speaker questionnaire for the N.Y. Inter-Group office. He provided his contact information and indicated availability to speak to various groups including junior high, senior high, college, and graduate students as well as religious, civic, business, and senior citizen groups. Lepkowski has been sober since 1988 and is over 60 years old. He is available most days of the week in the evenings and can provide his own transportation.

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    © All Rights Reserved
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    13 views1 page

    4 PI Volunter Sign Up Form

    Uploaded by

    Michael Kennedy
    Rick Lepkowski completed a volunteer speaker questionnaire for the N.Y. Inter-Group office. He provided his contact information and indicated availability to speak to various groups including junior high, senior high, college, and graduate students as well as religious, civic, business, and senior citizen groups. Lepkowski has been sober since 1988 and is over 60 years old. He is available most days of the week in the evenings and can provide his own transportation.

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    PUBLIC INFORMATION COMMITTEE

    VOLUNTEER SPEAKER QUESTIONNAIRE

    Please submit electronically or mail completed form to the N.Y. Inter-Group office.

    11/06/2017
    Today’s Date: ____________________________________

    Rick Lepkowski
    Name ___________________________________________ May we leave a message on Voice Mail? (Check Yes or No)

    rlepkowski@hazeldenbettyford.org
    Email ___________________________________________ (914) 941-0554
    Home Phone _______________________ ✔ No ____
    Yes ___

    29 Stone Ave
    Street ___________________________________________ (914) 502-7230
    Cell Phone __________________________ ✔ No ____
    Yes ___

    Ossining
    City ____________________________________________ (646) 601-7030
    Work Phone _________________________ ✔ No ___
    Yes ___

    NY Zip Code _________


    State _____ Westchester Occupation (Optional) __________________________
    10562 County ______________ Nonprofit Executive

    07/29/1988 Home Group Name ________________________________________________


    Sobriety Date _____________ The Book Shop (Manhattan)

    In which age group are you?

    ✔ 60 & Over _______


    Under 20 _______ 20-29 _______ 30-39 _______ 40-49 _______ 50-60 _______

    No
    What language do you speak fluently other than English? ______________________________________________

    To which of the following groups would you like to speak?


    ✔
    ______Junior High School Students ✔
    ______Religious Groups

    ✔
    ______Senior High School Students ✔
    ______Service/Civic Groups

    ✔
    ______College Students ✔
    ______Business Groups

    ✔
    ______Graduate Students ✔
    ______Senior Citizens' Centers

    ✔ Yes ______ No
    Are you available for anonymous interviews for T.V., Radio & Print? ______

    In which geographic area will you speak?


    ✔ Brooklyn ______ Bronx ______ Queens ______ Staten Island ______ Westchester ______
    Manhattan ______ ✔

    When are you most available? (check as many as you wish)

    ✔ Tues. ______
    Mon. ______ ✔ Thurs. ______
    ✔ Wed. ______ ✔ Fri. ______ ✔ Sun. ______
    ✔ Sat . ______
    ✔
    Mornings _________ ✔
    Afternoons _________ ✔
    Evenings _________

    ✔ Yes ______ No
    Can you provide your own transportation? ______

    Inter-Group Association of Alcoholics Anonymous of New York, Inc. ● 307 Seventh Avenue ● Suite 201 ● New York, N.Y. 10001-6007
    www.nyintergroup.org ● publicinformation@nyintergroup.org ● Phone: (212) 647-1680 ● Fax: (212) 647-1648

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