Air Quality Community Engagement Panel
If you experince any trouble completing this form, please reach out to programs@cooloc.org, and we will be happy to assist you.
Name
*
First Name
Last Name
Verify your email
*
Email
*
example@example.com
Phone Number
*
Please enter a valid phone number.
Please verify that you are human
*
You must live, work or go to college in Orange, Anaheim, Fullerton, Buena Park or Santa Ana and have a valid address to prove it. Do you understand?
*
Yes
Other
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Do you need childcare?
*
yes
no
This is just the sign up form. You will need to complete a separate survey that is will be emailed to and do your best to attend two meetings in person. We can compensate you $50 for each of the two meetings for your participation. Childcare, meals and Spanish translation are available.
*
Yes I understand
What meeting(s) can you attend?
April 10th, 6:00pm - 7:30pm (location will Fullerton or Anaheim)
May 1st, 6:00pm - 7:30pm (location will be in Anaheim)
Survey
Any other questions or comments?
How did you hear about this project? Please be as specific as possible by listing the name or partner that referred you.
*
Thank you! We will send you the survey shortly and be in touch with the meeting times.
Submit
Should be Empty: