East Bay Policy Leadership Program Registration Form

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Name* This field is required.
First Name
Last Name
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Email* This field is required.
example@example.com
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Phone Number* This field is required.
Please enter a valid phone number.
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Employer or School* This field is required.
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Please tell us about your career, including job title, major responsibilities, and how long you've worked in your field. If you're a student, please tell us about your studies and how long you've been in college/when you plan to graduate.* This field is required.
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Looking ahead, please tell us more about your career goals, including how your current work/field of study relates to public service/policy.* This field is required.
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Please tell us why you want to participate in the East Bay Policy Leadership Program.* This field is required.
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Which Task Force(s) are you interested in?* This field is required.
Health
Infrastructure
Water, Energy, & Environment
All of the Above
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Do you consent to receiving communications from the East Bay Leadership Council about the East Bay Policy Leadership Program and other related messages?* This field is required.
Yes
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Do you consent to EBLC using your written reflections and/or photos from task force meetings in our internal or external communications?* This field is required.There is no right or wrong answer here, we just want to respect your preferences.
Yes
No
It depends
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Please tell us more about your previous answer.* This field is required.
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By submitting this application you agree to be respectful to others in all spaces, including but not limited to social media platforms, Task Force meetings, EBLC events, etc. and understand that we have the right to ask you to leave the program if you violate this agreement. Thank you for contributing to an environment of inclusivity for all.* This field is required.
I Agree
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Someone from EBLC will contact you shortly with more information and next steps. If you have any questions, please include them below.
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