Peoples' Senate Interest Form

1

Name

First Name

Last Name

2

Email

example@example.com

3

Phone Number

Please enter a valid phone number.

4

City/State/Region

5

Did you attend the Spirit of Mandela 2021 International Tribunal?

Yes

No, but I am otherwise involved and aware of the SoM Tribunal Outcomes/Committees

No

6

Are You Representing an Organization? If so, what Organization?

7

In 1-2 sentences, describe your Organizational Mission/Goals

8

Do you or your organization currently organize around any of these issues of Genocide? (Select All that Apply)

Racist police killings of Black, Brown, and Indigenous people

Hyper incarceration of Black, Brown, and Indigenous people

Political incarceration of Civil Rights/National Liberation era revolutionaries and activists, as well as present day activists

Public health racism and disparities and its impact on Black, Brown, and Indigenous people

Environmental racism and its impact on Black Brown, and Indigenous people

Genocide of Black, Brown, and Indigenous people as a result of the historic and systemic charges of all the above

Other

9

How did you hear about the Peoples' Senate?

Email

Social Media

Word of Mouth

Paper/Mailing

10

If word of mouth, who?

11

Optional: Based on the "Peoples' Senate At A Glance," please share any thoughts you have

12

Are You Available to Attend the Peoples' Senate Informational Webinar, Scheduled for February 18, 2023 at 12pm EST?

Yes

No