home//made participation form
thank you for participating! epli will not be able to work with everyone but will do her best to work with as many people as possible. she will be in touch when planning a trip near you. epli is particularly looking to working with more BIPOC, elders, and trans women - please spread the word!
full name
*
First Name
Last Name
nickname // preferred name
e-mail
*
example@example.com
phone number
*
Please enter a valid phone number.
address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
pronouns
*
children's names and ages?
*
your parenting name (optional)
gender identification (how do you describe your gender, if at all)
social media handles (optional)
if you have a partner, partner's name (optional)
do you identify as Black, indigenous, or a person of color? (optional)
ethnicity (optional)
age (optional)
how did you hear about home//made?
Comments
please upload a photo of yourself
*
Upload a File
Drag and drop files here
Choose a file
Cancel
of
Submit
Should be Empty: