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Us@250 Event Registration Form
Please complete the following registration form to reserve your space at our upcoming community event! Friday, January 31st 9:30AM-2:30PM at the Salud Center - 3039 E. 91st St. Chicago IL 60617
Name
*
First Name
Last Name
Gender
*
Please Select
Female
Male
Non-binary
Transgender
Other
Race
*
Please Select
African American/Black
Asian
Caucasian/White
American Indian/Alaskan Native
Hawaiian/Pacific Islander
Biracial
Multiracial
Other
Address
*
Street Address
Street Address Line 2
City
Please Select
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
State
Zip Code
Email
*
example@example.com
Mobile Number
*
Language Preference
*
Please Select
English
Spanish
Dietary restriction (if any):
Do you require any special accommodation(s)? If so, please describe here:
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What is your level of involvement in discussions about social justice issues?
*
Not at all involved
Slightly involved
Moderately involved
Very involved
Extremely involved
How important do you think it is to have conversations about race and identity within your community?
*
Not important at all
Slightly important
Moderately important
Very important
Extremely important
To what extent do you believe that racial or cultural differences impact how people interact in your community?
*
Not at all
To a small extent
To a moderate extent
To a large extent
To a very large extent
To what extent do you believe that community efforts to emphasize diversity and inclusion will benefit you personally?
*
Not at all
To a small extent
To a moderate extent
To a large extent
To a very large extent
Submit
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