Mosaic Cooperative Membership Intake
After you submit the form, a core or cadre member will contact you to set up a time for a 3:1, learn more about you, and chat about our work. If you aren't eligible to be a Mosaic Cooperative member, please feel free to follow us on social media to keep up with and share our work on Instagram:@mosaiccooperative or Facebook: Mosaic Cooperative
Name
*
First Name
Last Name
Email address
*
example@example.com
Pronouns
*
ex: he/him/his, name only, they/he, they/them
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Where are you located?
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Age
*
Under 18
18-24
25-34
35-44
45-54
55+
Gender
*
Trans man / Man of trans experience
Transmasculine
Non-binary
Agender
Genderqueer
Genderfluid
Gender non-conforming (GNC)
Other
Who referred you to Mosaic Cooperative? Have you come to any events?
*
Ex. "I heard about Mosaic from August and Isaiah who are members. I also attended the 2023 Retreat and Pride Cookout!"
Why would you like to become a Mosaic Cooperative member?
*
Feel free to share 2-3 sentences about yourself, your interests, and how you're looking to show up in Mosaic Cooperative!
I am most interested in this work within Mosaic Cooperative:
*
People's distributions
Community building
Harm reduction organizing
Land-based work
Political education
Other
What days/times work best for Mosaic to schedule a 45-minute zoom meeting with you?
*
Weekdays 9am-5pm
Weekdays after 6:00pm
Weekend afternoons
I have open availability
Other
Do you have any social media you'd like to share with us?
Ex. Instagram - @mosaiccooperative, Facebook - Mosaic Cooperative
Submit
Should be Empty: