Education Reform Champion Form

1
Name* This field is required.
First Name
Last Name
2
Email* This field is required.
example@example.com
3
Phone Number* This field is required.
Please enter a valid phone number.
4
T-Shirt Size* This field is required.
XS
Small
Medium
Large
X-Large
2XL
3XL
Other
5
Which race or ethnicity best describes you?* This field is required.Please select one.
American Indian or Alaskan Native Asian
Asian or Pacific Islander
Black or African American
Hispanic or Latino
White / Caucasian
Multiracial
Other
6
Gender* This field is required.Please select one.
Woman
Man
Non-binary
Trans Woman
Trans Man
Two-Spirit
Other
7
Occupation* This field is required.
8
Employer* This field is required.
9
Address* This field is required.
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Please Select
Please Select
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
The Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Cook Islands
Costa Rica
Cote d'Ivoire
Croatia
Cuba
Curaçao
Cyprus
Czech Republic
Democratic Republic of the Congo
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Polynesia
Gabon
The Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
North Korea
South Korea
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Nagorno-Karabakh
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Turkish Republic of Northern Cyprus
Northern Mariana
Norway
Oman
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn Islands
Poland
Portugal
Puerto Rico
Qatar
Republic of the Congo
Romania
Russia
Rwanda
Saint Barthelemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
Somaliland
South Africa
South Ossetia
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard
eSwatini
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Transnistria Pridnestrovie
Trinidad and Tobago
Tristan da Cunha
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
British Virgin Islands
Isle of Man
US Virgin Islands
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Other
Country
10
Pronouns* This field is required.
She/her
He/him
They/them
Other
11
Birthday
Date
Month
Day
Year
12
Are you registered to vote?* This field is required.If not, please consider registering to vote here: https://vr.dcboe.org/213324797239968?agency_code=12
Yes
No
N/A
Not Sure
Other
13
City Ward* This field is required.What DC City Council Ward do you reside in? Go here to find your ward: https://planning.dc.gov/whatsmyward
14
Community Engagement Interests* This field is required.
Running for Office in 2024
Host a House Party
Serve as a Media Spokesperson
Organize Voter Registration Drive
Canvass
Write Postcards
Collect Petitions
Write a News Opinion Article
Testify Before DC Council/State Board of Education
All of the Above
Other
15
When are you usually available for community events and engagements? * This field is required.
Mornings during the week
Afternoons during the week
Evenings during the week
Weekends
Saturday Mornings
Saturday Afternoons
Sunday Mornings
Sunday Afternoons
Friday Afternoons
16
Which of these describe you best?* This field is required.
Parent of a Student at DC Public Charter School
Parent of a Student at DC Public School
ANC Member
Teacher
Educator
Advocate
High School Student
Charter or DCPS School Principal
School Staff Worker
Community Leader
Member of a Political Organization
Faith Leader
Business Owner
Member of the LGBTQ+ Community
Veteran
Other
17
Please let us know the name of the school your child attends?If you have multiple children, please name all the schools.
18
What school(s) do you work with?
19
Please Attach a HeadshotOptional
Drag and drop files here
Select files to upload
Cancelof
20
I commit to taking three public actions in 2023.* This field is required.
Yes, I agreeNo
21
I commit to attending in-person engagements hosted throughout the year and subscribing to the newsletters.* This field is required.
Yes, I agreeNo
22
I commit to recommending three people to become Education Reform Champions.* This field is required.
Yes, I agreeNo
23
I am over the age of 18 years old. * This field is required.
YESNO
24
I, First Name Last Name parent/guardian of First Name Last Name , grant permission to Education Reform Now Advocacy DC to use photographs and/or videos of my child for publications, news releases, online, and other communication related to the organization. Signature Date
Should be Empty: