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Application
Application to participate in the Civic Engagement Program
Please provide the following information to apply for a childcare scholarship. Once we approve your scholarship request, you will be able to request funding for specific events. At this time we are working with clients in Oregon and North Carolina. We are hoping to expand to other states soon, so please let us know if you'd like us to be in touch at that time.
Name
*
First Name
Last Name
Email
*
example@example.com
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Please answer the following demographic questions to assist us in our work.
When seeking funding for Politisit to assist clients, this information is often important in applications to donors or for receiving grants. We also want to ensure we know which communities we are and are not serving well, in order to improve. Politisit is committed to maintaining your privacy. Thank you.
How do you describe your gender? (Select all that apply)
*
Female
Male
Non-binary
Transgender
Prefer not to answer
Other
How do you describe your sexual orientation?
*
Heterosexual or straight
LGBTQIA+
Prefer not to answer
Other
What is your age range?
*
18-25
26-35
36-45
46-55
56-65
66-75
Prefer not to answer
Other
What is your ethnicity?
*
White
Hispanic, Latino, or of Spanish origin
Black or African-American
American Indian or Alaska Native
Native Hawaiian or Other Pacific Islander
Asian
Other
What is the highest degree or level of school you have completed? If currently enrolled, highest degree received.
*
No schooling completed
Less than high school or GED
High School/GED
Trade/technical/vocational training
Associate's Degree
Bachelor's Degree
Master's Degree
Professional Degree
Doctorate Degree
Prefer not to answer
Other
What is your current marital status?
*
Single, never married
Married or domestic partnership
Separated
Divorced
Widowed
Prefer not to answer
Other
What is your annual household income?
*
$0-$9,999
$10,000-$24,999
$25,000-$49,999
$50,000-$74,999
$75,000-$99,999
$100,000-$149,999
$150,000-$199,999
$200,000-$249,999
$250,000+
Prefer not to answer
Do you consider your home to be located in an area that is:
*
Urban
Suburban
Rural
Other
The following questions assist us in understanding program impacts going forward:
How many children will you usually need care for?
*
What are the age ranges of your children? (Select all that apply)
*
0-3
4-6
7-9
10-12
13-15
What is your babysitter’s usual hourly rate?
*
$5-$10
$11-15
$17-20
$21-25
Other
In an average month, how many hours of civic engagement do you currently participate in? In this application, when we say civic engagement, we mean attending events such as school board meetings, city council meetings, meeting with elected officials, advocacy trainings, PTA meetings, voting,etc. without being compensated or as part of a job/internship.
*
0-2
3-5
6-8
9-10
11+
Prefer not to answer
What types of civic engagement activities are you currently participating in?
*
What, if anything, currently holds you back from civic engagement?
*
What reasons are you interested in using Politisit?
*
Is there anything else you’d like us to know or consider in reviewing this application?
*
How did you hear about Politisit?
*
Politisit Website
Social Media
Word of Mouth/Friend
Flyer
Other
Declaration
You declare under penalty of perjury that all the information provided on this form is true and correct to the best of your knowledge. You understand that anyone who knowingly gives a false or misleading statement in this electronic form, or causes someone else to do so, commits a crime and may be subject to penalties under Federal and/or state law. By signing, I declare that everything in this form is true to the best of my knowledge.
Signature
*
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