Mosaic Cooperative Member Intake Form

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 NameLast 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.
Where are you located?*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Age*

Under 1818-2425-3435-4445-5455+
Gender*

Trans man / Man of trans experienceTransmasculineNon-binaryAgenderGenderqueerGenderfluidGender 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 distributionsCommunity buildingHarm reduction organizingLand-based workPolitical educationOther
What days/times work best for Mosaic to schedule a 45-minute zoom meeting with you?*

Weekdays 9am-5pmWeekdays after 6:00pmWeekend afternoonsI have open availabilityOther
Do you have any social media you'd like to share with us?
Ex. Instagram - @mosaiccooperative, Facebook - Mosaic Cooperative
Should be Empty:

Mosaic Cooperative Membership Intake