Virtual Support Group
MADD New York & New Jersey
Full Name
*
First Name
Last Name
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
*
E-mail
*
example@example.com
Have you been impacted by a substance impaired driving crash?
*
Please Select
YES
NO
If yes, what was the crash date?
*
If you are comfortable with sharing, please describe the victimization .
Please share any concerns or questions you may have in participating in the Virtual Support Group.
Registration Information:
Thank you for registering. Following submission you will receive additional information from support group fascinator, Rachael Browngardt. Important information and access to our virtual support group will be provided via email. If you have any questions or concerns, please contact Rachael at (585) 426-3130 or via email Rachael.Browngardt@madd.org.
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