Angelenos For Clean Air (ACA) Membership Form 2022-2023

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 NameMiddle NameLast Name
Date of Birth*

MonthDayYear
Gender*
Phone Number*
Please enter a valid phone number.Format: (000) 000-0000.
Email*
example@example.com
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
American Indian/Alaskan NativeAsianBlack/African AmericanLatino/HispanicNative Hawaiian/Other Pacific IslanderWhiteOther
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
Effects of Secondhand SmokeSecond-hand Smoke PoliciesProtecting my child from second-hand smoke exposure in my homeTalking to landlords about my concernsTalking to my neighbors about my concernsTalking to elected officials about my concernsOther
SmallMediumLargeX-LargeXX-Large
Should be Empty:

Angelenos For Clean Air Membership Form 22-23