Roots to Branches Application Form

Roots to Branches Application Form

Brought to you by Action Dignity's BLACK Project and Woezo Africa Music & Dance Theatre Inc. Roots to Branches aims to tell the stories of Black youth in Calgary (ages 12-22.) This form will provide us with some background information about you, as well as give you a chance to share a story of your lived experience.
Name*

First NameLast Name
Email*
example@example.com
I am blanks* years old.
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Which of the following is true about your story? (Check all that apply)

My story has already happenedMy story is currently happeningMy story will be happening in the futureOther
Which of the following themes fit your story? (Choose all that apply.)*

Anti-Black RacismColourism/ShadeismMicroaggressionsSystemic RacismDiscriminationBullyingExclusionPolice BrutalitySlurs/Racist languageBarriersInternalized RacismHarassmentExploitationOppressionRacial ProfilingVictimizationFamily Dynamics (ie. single parents, immigrant families, etc.)TexturismOther
In the box below, please tell us a summary of your story.*
Some examples for stories could be a lived experience with racism, systemic racism, colourism, microaggressions and so on. This is not an exhaustive list, so please feel free to tell your story as you see fit.
How have you overcome this experience?*
If it feels like you haven't overcome this experience, or it's still negatively impacting you - please feel free to elaborate on the aftermath of your story. Where are you now? If your story is occurring in the future, answer this question however you see fit.
Is there anything else you would like us to know?
I, blanks (write your full name in the blank,) consent to this application being read by the Roots to Branches Project Coordinator, and the possibility of being contacted in the future.
Upload Headshot*

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