l
Dear Prospective AMIAS
The paperwork necessary to complete your certification as an Area 51 ,Al-Anon Member lnvolved in
Alateen Service is included in this AMIAS Application Packet. Complete the registration form and be
sure to have your District Representative sign it if you have one. ln addition, please glve two names for
reference. Be sure to sign all forms.
You will have to get a fingerprint card from your local law enforcement agency. Please stress that the
prints need to he clear to enable the Crime Bureau to read them. lf they have a digital print machine,
the prints are usually much better. NOTE: I would advise calling them before you go as many only do
this on certain days of the week. Also, be sure to complete all the information on the card. NOTE: The
AKiq block should indicate your maiden name{s). Keep your receipt in case the fingerprints need to be
repeated. They won't charge you the second time.
Forward all forms to the Area Alateen Process Person (AAPP). You can find the e-mail link on this web
page under Contact Area Officers and Coordinators. Since you will have to mail the fingerprint cards.
you will need to contact me for my mailing address.
Requirements for Al-Anon Members lnvolved in Alateen Service are found on the Area 61 Alateen Safety
and Behavioral Requirements which can be found on this web page.
FORMSATTACHED:
Waiver Agreement and Statement for State of Wisconsin
Privacy Statement
Authorization for Release of lnformation for Wisconsin Al-Anon/Alateen, lnc.
Area 61 Alateen Sponsorship Registration Form
Al-Anon Member lnvolved ln Alateen Service for WSO
PROCESS:
Fingerprints returned to the AAPP are sent to Wisconsin State Crime lnvestigation Bureau {ClB)
ln about two weeks, the MPP checks their lnternet data base for results (Approved OR
Rejected)
lf the fingerprints are rejected for "quality", the applicant is asked to have them redone.
lf rejected for the same reason a second time, the AAPP determines if the Area 61 Sponsorship
form has the required signatures for approval.
lf so, the AAPP signs the AMIAS Form approving the applicant and fonrrards to WSO.
WSO records information and assigns AMIAS an lD number. They return to the AAPP as certified
The A4PP sends an approval letter to you and e-mails your District Representative if there is
one.
You will also be sent the six page Area
6l Training Manual, dated
2007 which will give you
enough information to get you started.
IF YOU HAVEN'T ALT READY DONE SO, YOU
WILI NEED TO ATTEND A FORMAL AMIAS TRAINING.
That training is done at the Spring & Fall Assemblies and I will work with the Alateen Coordinator to
schedule some on an as needed basis.
Every year WSO requires that all areas conduct a recertification process, You will be contacted in March
or April, so be sure to keep your address and group information updated.
Revised 5-15-13
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STATE OF 1{rISCSN$IN
I}EPAR.TMET.TT SF JUSTECE
DTWSION OF' LAW INFIORCIMENT SERI/TCES
Cdmc fdomatioa BgrEau
P,O. Box 2688
Madison"
Record CheckUnit
lYI S70Ia688
608r266,s?64
WANIER AGREEMENT AT{D STATEMETTIT
I hereby authorize the agency listed below to submit a set of my fingerprints to the Wisconsin Departrnent of
Justice and the Federal Bureau of Investigation for the pqpose of accessing aad reviewing Wisconsin and
national cdminal history records that may pertain to me_
By signing this waiver agreement it is my intent to authorize dissemination of zuch criminal history record
information that may pertain to me to the agency with which I am employed seeking employment with, seeking
to serve as a volunteer for, orseeking iicensure &our- I also understand that &is information may only be used
forthe purpose itwas zubmitted.
I understand that it is not employment discrimination because of arrest record to reflse to employ or license, or
to suspead from employment or licensirg, any infividual who is subject to a pending criminal charge or has
been convicted of any felony, misdemeanor or other offense if the circumstances of the offense or cbarge
substantially relale to the circumstarces ofthe particularjob or liceflsed activity.
I
have been informed of my right to obtain a copy of the criminal history records, if any, and of my right to be
given a reasonable amourt of time to chailenge the accuracy and or to complete any information contained in
the criminal history record. The procedwes for obtaining a change, correction, or updating of an FBI
identification record are set forth in &e Code of Federal Regulations (2S CfR 16.34).
N*me:
Address:
Date:
Witness;
Name of Agency:
Agency Address:
Signature:
US Department of Justice
Federal Bureau of Investigation
Criminal Justice Information Service s Div ision
Wiscousin Depa rtuent of Justice
Division of Law Enforcement Services
Ci me l4fo rtn a ti o n Bur e a u
@ryr
r'uthoritv: rhe FBl's-acc:1":d*
,*""*.rffi
tr::-ation
requested by rhis fonn is generauy
authorized rmder 28 U-S',C- 534- Depending on the nature of yoL application, supplemental au&orities
include numerous
Federal stafises, huadreds of-State statutetpu$u&t to Pub.i. 92-544, Prmidenkal
execrdive orders, regulations and/or
orders of the Attomey General of the united States, or ofier authorized althorities.
Examples include, but are not limited
to:5
U'S-C' 9l0t; Pub-L- 94-29; PubI. t0l{o4; and Executive tuers 10450 and li96E. providing
the requested
information is volunary; however, failure to firnish &e information may affect timely completion or aiproval
of y*r.
application.
Social Security Account Number (sSAlrQ: Yow SSAN is needed Io keep records accurate because other people
may
have the same name and birth date. Pu$uant to the Federal Privacy AL.t of lg74 (5 USC 55?a), theoqo"tirrg aiency
is
responsible for informing you whether disclcsure is mandatory or voluntarjr, by what statutory or otler u,rtt crrity you,
SSAN is solicited, and what uses r'ryill be made of it Executive,Order 9397 also asks Federal agencies to use this number
to help identifr individuals in ageary rec,ords-
Prircipal Purpose: Certain determinations, such as employment, securiry" ticensing, and adoptiorl may be predicated on
fingerprint based checks- Your fingerprinB and other information
with) iUi, io.* may be
""-(*A along
"ontuin"a
submitted to the reques!1g-u8"tty, the ageacy conducting the applioation
itvestigation,
*d/or nBi forthe pr:rpoie of
comparing the submitted informaiion to available recnrds in order to idertify othei information that may be pertLent to
the application. During the processing of this applicaiorq and for as long he-rea€er as may be relevaut; the;divity for
which this application is being submitted, the FBI may disclose any poentiatly pertineni information to the requesting
agency and/orto the agency conduaing the irvestigatioa- The FBI may also retain the submitted information in the FBI's
perma[ent collection of fingerprints and related information, where it will be subject to comparisons against other
submissions received by the FBI. Depending oa the nature of your application, the rJquesting ag"ncy and/oitne agency
conducting t}le application investigation may also retain the fingerpriars and other submitted information for other
authorized purposes of such agency(ies).
Rontine Uses: The fingerprints and information reported on this form rnay be disclosed pursu111t to your consen! and
may also be disclosed by the FBI without your consent as lermitted by the Federal PrivacjeAct of l97i (5 USC 552a(b))
and all applicable routine uses as may be published at any time in the Fedsral Register, including the routine uses for the
FBI Fingerprint Identification Records System (Justice/FBl-009) and the FBI's Blanket Routine Uses (JusticeffBI-BRU).
'Or
Routine rses include, but arc aot limited to, disclosures to: appropriate
tovcrnmsntal authorities responsible for cidl
criminal law enforcemenl counterintelligence, national security or public safety matters to which theinformation rnay be
relevant to Slate and local governmental agencies and aongovernrnental entities forapplication processing as authorized
by Federal and Sate legislation, executive order, or regulation, including employment, security, licensing, and adoption
ehecks; and as otherwise authorized by taw, treaty, executive order, regulation, or other lawful authority. tiottrer agencies
are involved in processing this application, they may have additional ror[ine uses.
Additional Isformation: The requesting agency and/or the agency conducting the application investigation will provide
you additional information pertinent to the specific circumstances of this application, which may include identificition of
otherauthorities, purposes! uses, and consequences ofnot providing requested information. In addition, any such agency
in the Fedcral Exccutive Branch has also pubtished notice in the Federal Register describing any system(sj of records in
which that agency may also maintain your records, including the authorities, purposes, and routine uses for the system(s).
I have read, understand and agree to the use ofinformation provided as detailed above.
Signature
AUTHORIZATION FOR RELEASE OF INFORMATION
I hereby empower Wisconsin Al-Anon/Alateen, lnc. to obtain through the Criminal lnvestigation
Bureau (ClB) a copy of my arrest records maintained by the Federal Bureau of lnvestigation and the
Wisconsin Department of Justice associated to me pursuant to a search based on a fingerprint
submittal within one Year of the date on this form.
I also understand
that federal law prohibits the sharing of this information with anyone other than
the Area 61 Alateen Process Person (AAPP).
the
I also have the right to obtain a copy my criminal history records, if any, and the right to challenge
accuracy and completeness of any information contained in the criminal history record when obtained
other than by fingerprint. That is by name, social security number, etc.
only. I understand
I have a
right to obtain a determinetion as to the validity of such challenge before final determination
regarding associaticn with Wisconsin Al-Anon/Alateen, lnc-
Full Name:
{Signature}
Current Address:
{Number & Street)
(City/state/Zip)
Date:
Revised 5-3-13
Angn Ar A1.1qtefru
SpONSCIRSHtp RSCISTRATION FOnnA tslosl telosl
Today's Date
Previous l\a
Add
7i
State
City
Alternate
Phone
Phone
Email
Date of Birth
Place
of
Bi
{City, County, & State)
s5#
Sex:
M*--F.
District
Race
-
Alateen group name & nurnber if established group:
If not an established group, remember to
Change Form (6R-3).
#,
fill out an Alateen Registration/GrouB
Records
Al-Anon group name & number if associated with Alateen group
Provide the names cf two Al-Anon personal references that are not related to you.
These references should be able to attest to your participation in the program, service
experience, reliability, and dependability.
Name
Phone#
Narne
Applicant Sign
*signing this form gives Area 51 permission to do a background check'
Update your troup and AMIAS registrations by submitting thenr to the current Area
61- Alateen Process Person each year. NOTE: Groups that are not in cornpliance with
Area Sl guidelines will not be registered with WSO and will not be listed in schedules,
answering services, or Web Site.
Any question regarding the registration of Alateen group or AMIAS guidelinesforms
may be directed to Area 61's current Alateen Process Person.
have reviewed this as District Representative for District
l"{/LL DOCS-JtlNI{.docx
\Aleb: www.area6:,afg,or8
Pgl
of
I
:
_ __ - _-rv-r
Al-Anon
Member
av^vrrrErt/r,
r.tl y frl y t/l.I In
lnvolved
tII
Alateen
rr.,.}l.,rt II lJl,l
Service
Service
vlrLru
It-,
|I
a
L
It is requked thatthis tarm be compteted by att At-Anon memfurs involved in servie to Alateen.
(Plax
Pdnt)
First & Last Hame:
Street Addrcss:
City, State/Province:
ZiplPostal Gode/Phone:
e-mail:
I gy_in- compliane wlth my arca's srltety and
abtde bythem.
bhaviont rqutrcments and agree to
Date
To the &€.st of my knowledge, the above AI-Anon membrrneefs the area's safety
and bhavionl rqulrements.
Authorized Area
Signature
Area#
Please Pfint Name Belaw:
Date
to the wso annually that sch AhAnon memfur lnvolved in
Alateen servle has met the area's safeti and behavioral rcqulrcrnents and has
agreed to abide by them.
wso Assigned
it"igr"d lD
tp Number:
Nr*
l WSO
Each area must @rttfy
'
For Area Use:
riPre
r.vw
I
I
I
Anne 61 AmrrEN SerrrY AND Busavtonqr RSQUIREMENTS
lnformation may be found in the following Conference Approved Literature publications:
. Guide for Sponsors of Alateen Groups (P-29)
.
.
Al-Anon/Alateen Service Manual
-
{P-24127\
Alateen Safety Guidelines 6-34
Additional information may be found in the following:
r
.
r
Area 61 Policy Manual
Area 6L's Role of Sponsors
Al-Anon Board Motion of December 2003 {WSO)
WHo WIIT ARTR 61 RTcocNIzf, As
(AMTAS)?
AN
AL-ANoN MEMBER IIUvOIVTO IN ALATEEN SERVICE
A recognized Al-Anon Member lnvolved in Alateen Service (AMIAS) is a responsible adult member of
Al-Anon who attends Al-Anon regularly and who shares his or her recovery experience gained
through working the 12 Steps, 12 Traditions and 12 Concepts. He or she will have passed the Area
61's requirements for AMIAS. He/she helps the Alateens to focus on the Al-Anon prograrn. lt is in
sharing recovery that we provide hope for the future.
Requirements for Al-Anon Mgmbers lnvolved in Alateen Service
1.
Every Al-Anon member {including, but not limited to Sponsors, substitute sponsors,
transportation providers, etc.) involved in Alateen service must:
a.
b.
c.
Be an A[-Anon member regularly attending Al-Anon meetings.
d"
Not have been convicted of a felony, and not have been charged with child abuse or
any other inappropriate sexual behavior, and not have demonstrated emotional
problems which could result in harm to Alateen members. A child abuse and criminal
records background check will be required for all adults involved in Alateen Service.
Be at least 23 years old.
Have at least two years in Al-Anon in addition to time spent in Alateen.
2.
There must be at least one Alateen Sponsor at every Alateen meeting. Note: Although not
currently a requirement by Area 51, we strongly suggest that each group have two sponsors.
3.
The Area prahibits overt or covert sexual interaction between any adult and Alateen
member.
Area
4.
Any conduct contrary to applicable State of Wisconsin or State of Michigan laws is strictly
prohibited by Area 6L.
5.
Area 61" requires procedures for Participating Minor lnformation and Permission Forms when
applicable (See Area 61 Policy Manual for these forms.) The name sf Alateen can only be
used with functions in perticipation with or in conjunction with the structure of Area 61 AlAnon Family Groups.
6l Al-Anon/Aiateen
Policy Manual 2012
Edition
www,erea6lafs,org
Page 1
of2 - Revised 5112/20L3
l
Process
1.
Contact the District Representative (DR) to let them know of your desire to become an AlAnon Member lnvolved in Alateen Service and complete necessary forms: Area 61 Alateen
Sponsorship Registration Form, Al-Anon Member lnvolved in Alateen Service, and Alateen
Registration/Group Records Change Form (6R-3). Remember to have your DR sign your form.
lf your District is not represented contact your Area Alateen Coordinator or the Area Alateen
Process Person {AAPP).
2.
Obtain one fingerprint card from the Area 61 AAPP. Go to your local law enforcement agency
and have your fingerprints taken. Mail all forms and fingerprint cards to the AAPP.
3.
Pass
4.
Change the Alateen Registration/Group Record Change Form tGR3) if you are the group's
regular sponsor. The AAPP will forward the forms to WSO to register or update the group.
5.
The AAPP will contact you and your DR to let you know of your registration.
6.
the background check.
Update your group and sponsorship registrations, by submitting them to the current Area 61
AAPP each year by January 3L or date determined by WSO.
NOTE: Groups that are not in compliance with Area Sl Guidelines will
not be registered vuith WSO and will not be listed in schedules,
answering services or Web Site.
Area 61Al-Anon/Alateen Policy Manual 2012 Edition
www.a rea6lafq.orq
Page? of2 - Revised
5/L2/2013
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