Name
*
First Name
Last Name
Date of Birth
*
-
Month
-
Day
Year
Phone Number / Email
*
Please enter a valid phone number.
example@example.com
Full Mailing Address
*
In Case of Emergency Contact:
*
Emergency Contact Full Name:
Emergency Contact Phone Number:
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Interested in government relations/public policy?
*
Want to know what lobbyists do?
*
Current Employer
*
What is Your Local Newspaper?
*
Are You A Registered Voter?
*
Please Select
Yes
No
If yes, then in which state are you registered to vote?
*
Have you held a public office?
*
Please Select
Yes
No
Are you interested in running for public office in the near future?
*
Please Select
Yes
No
Maybe
Are you interested in working on a campaign outside your state?
*
Please Select
Yes
No
Maybe
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In 1,000 characters or less, please answer the following three questions?
1. Tell us what inspired you to become civically engaged.
*
2. What do your hope to achieve by participating in this training?
*
3. In today’s political climate, what is the most critical issue facing our communities? What solution(s) do you propose?
*
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Please indicate your shirt size (polo style)
*
Please Select
small
medium
large
xtra large
Upload your headshot:
*
Browse Files
Drag and drop files here
Choose a file
Cancel
of
Upload your vaccine information.
*
Browse Files
Drag and drop files here
Choose a file
It should indicate at least one current booster shot
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Please provide the name of the U.S. Representative’s district in which you reside.
*
How did you hear about CBCI Boot Camp?
*
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