Civic Influencer Registration Form

Civic Influencer Registration Form

Norwalk ACTS is excited to launch a Civic Influencer cohort for Norwalk ACTS Members affiliated with partner organizations and strives to compile a cohort that represents the diversity of Norwalk. Cohort composition decisions will reflect the individual identity and organizational diversity of the community. Participant decisions will be made in mid-February. Please reach out to Kathleen Callahan (ctc2c.policy@gmail.com) with any questions.
Basic Information/Demographics
Name*

First NameLast Name
Email*
example@example.com
Which Norwalk ACTS partner organization are you affiliated with?*
What is your position in the partner organization?*
What is your race/ethnicity?*
What is your gender?*
What languages do you speak?*
Do you live in Norwalk?*

YesNo

Norwalk ACTS Memorandum of Agreement
Click here to view a list of all MOA signers
Have you or your organization signed the updated Norwalk ACTS MOA?*

YesNoUnsure
Please have your Organization's Leadership complete our MOA:

Click here to sign our new MOA

Consent, Accessibility, & Commitment
Some activities include completing surveys and online forms, as well as internet research. Will you need to borrow a tablet during the sessions to complete activities?*

NoYes
Do you have any learning needs that we should know about or that require accessibility modifications?*

NoYes
Please specify:
Do you have any dietary restrictions or needs?*

NoYes
Please specify:

Would attending these sessions create a financial hardship for you or your organization and you’d like more information about potential honorariums?*

NoYes
Is there any other information you’d like to share with us?

Norwalk ACTS Photo & Video Release
- I consent to the unrestricted use, by Norwalk ACTS (and those acting with its permission and authority), of any and all media taken, in whole or in part, unlimited use, for all purposes in any form or medium, including, without limitation, its use through or on any electronic media, including the Internet. I waive any right to inspect or approve the finished product or products or the advertising copy or printed matter that may be used with the finished media.
- Further, I relinquish all rights, titles and interest I may have in the finished media, negative(s) and reproduction to any responsible business firm or publication. It is understood that Norwalk ACTS retains copyright of media at all times under the express understanding and agreement that Norwalk ACTS shall have exclusive reproduction rights to the media.
Do you consent to having photos taken for Norwalk ACTS publicity purposes?*

YesNo
Should be Empty:

Basic Information/Demographics