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Angelenos For Clean Air Membership Form 22-23
Thank you for your interest in the Angelenos For Clean Air(ACA). ACA is a coalition that aims to educate community members about the effects of secondhand smoke in multi-unit housing. ACA's focus is in five of the fifteen council districts to better serve the residents of LA. These council districts include 4,9,10,12, and 15. This membership form will help us gain a better understanding of coalition members' needs and concerns. Thank you for your interest in becoming part of the ACA family.
Name
*
First Name
Middle Name
Last Name
Date of Birth
*
Please select a month
January
February
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April
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Month
Please select a day
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Day
Please select a year
2024
2023
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2012
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Year
Gender
*
Please Select
Woman
Man
Transgender
Non-binary
Prefer Not To Answer
Phone Number
*
Please enter a valid phone number.
Email
*
example@example.com
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Race/Ethnicity
*
American Indian/Alaskan Native
Asian
Black/African American
Latino/Hispanic
Native Hawaiian/Other Pacific Islander
White
Other
Which of the following best describes you?
*
I lease/rent a room, apartment, or other space. I am a tenant.
I live in student housing.
I live in transitional housing or a shelter.
I live in a senior care facility/community.
I am unhoused.
I own a single family home.
I own property that shares walls/common areas (townhome, condominium).
I own property which I rent out. I am a landlord/property owner.
I am a concerned community member.
Other
What kind of information would you be interested in learning about? (*select all that apply)
*
Effects of Secondhand Smoke
Second-hand Smoke Policies
Protecting my child from second-hand smoke exposure in my home
Talking to landlords about my concerns
Talking to my neighbors about my concerns
Talking to elected officials about my concerns
Other
Member T-Shirt. What is your size?
*
Small
Medium
Large
X-Large
XX-Large
Submit
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