Application to Join the Chapter

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
Race/Ethnicity * This field is required.
Please Select
Please Select
Black
White
Latin
Pacific Islander
Asian
Indigenous
Arab/ Middle Eastern
Another amazing race/ethnicity
5
Do you agree not to incite violence* This field is required.
I agree
6
Do you agree not to destroy property?* This field is required.
I agree
7
Are you a police officer or a member of law enforcement?* This field is required.
I am a police officer
I am a federal officer
I am a correctional officer
I have a family member or relative that is a police officer
I am dating a police officer/federal officer, or corrections officer
I am married to a police officer
I am not a police officer, and I am not related to a police officer
I have a friend or multiple friends who are police officers
8
Select a Committee* This field is required.
Please Select
Please Select
LGBTQIA+
Police Reform
Elections
Outreach
Black Lives Matter Summer Camp
Black Lives Matter Ski Camp
Museum
Education
Security
Murals
Disability Committee
9
Do you agree to the following rules; Black Lives Matter Rules and Regulations. 1. No member is allowed to incite violence of any kind. We only believe in self defense because all Americans have the right of self defense 2. No racial slurs. 3. No threats. Any member making threats of any kind towards a person place or thing will be blocked and removed. 4. No LGBTQ+ bashing. 5. No bashing of Black people, Latinx people, Asian People, Polynesian People, Pacific Islanders, Indigenous people at any time, for any reason. 6. We will not make other races comfortable with our oppression 7. The Black Lives Matter movement is Black led and will run that way. 8. We will not profit off of the movement, at any time for any reason. 9. Bashing other activists is not allowed. 10. Do not invite known troublemakers 11. Anyone attempting to cause division will be removed. 12. No destruction of property 13. We do not bash other people's religions ** This field is required.
I agree
10
How often do you plan to participate?* This field is required.
Please Select
Please Select
Daily
Weekly
Monthly
Yearly
Never I am a keyboard warrior
11
Do you understand that this chapter has never been a part of the "Global Network" of Black Lives Matter and we have been in existence before that organization even existed?* This field is required.
I understand
12
Select the statement that you believe with your entire heart* This field is required.
Black Lives Matter
Black Lives Matter
Black Lives Matter
Should be Empty: