Intake Form
Name
*
First Name
Last Name
Date of Birth
*
-
Month
-
Day
Year
Date
Age
*
Email
*
example@example.com
Phone Number
*
Please enter a valid phone number.
City of Residence
*
Occupation/Current Field of Study
*
What is your primary area of community focus or action? (Please select one that best represents your current work/interest)
*
Local Politics / Policy Advocacy
Business / Entrepreneurship
Education / Youth Development
Arts, Culture, & Media
Social Justice / Civil Rights
Health & Wellness Initiatives
Other
Share your involvement or interest in politics. Type NA if none.
*
Tell us about a recent project you lead that you are proud of. Share any links you may have.
*
Which platform do you prefer for our virtual meetings?
*
Please Select
Zoom
Google Meet
Both work for me
Availability
Which time slot generally works best for a monthly virtual meeting? (Please check all that apply)
1st Mondays
Morning
Afternoon
Evening
List the time-blocks you are available on Monday
Ex: 7am - 9am
1st Tuesdays
Morning
Afternoon
Evening
List the time-blocks you are available on Tuesday
Ex: 7am - 9am
1st Wednesdays
Morning
Afternoon
Evening
List the time-blocks you are available on Wednesday
Ex: 7am - 9am
1st Thursdays
Morning
Afternoon
Evening
List the time-blocks you are available on Thursday
Ex: 7am - 9am
I agree that I am a Black person between the age of 25 - 45 who is active in leading initiatives in the Modesto region.
*
I agree
Submit
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