Name *

First Name

Last Name

Phone

(###)

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What is your preferred method of contact?

Call

Email

Text

Birthday

We would like to acknowledge you on your birthday! Also, if you are under 18 years of age, you must be accompanied by an adult.

MM

DD

YYYY

Gender (Select all that apply.) *

For demographic purposes.

Female

Male

Non-binary

Prefer to self-describe

Prefer not to say

Race/ Ethnicity *

For demographic purposes.

Black/ African-American

Native American Indian or Alaska Native

Asian

Native Hawaiian or other Pacific Islander

White

Prefer not to say

What committee(s) are you interested in?

Please select the committee(s) you are interested in serving on.

Community Development Committee

Community Health Committee

Communications and Outreach Committee

Emergency Response Committee

Finance and Budget Committee

Food and Nutrition Program Committee

Fundraising and Development Committee

Governance and Nominating Committee

What are your favorite initiative(s)

This can also help us place you within our committees!

Annual M.L.K. Day Parade

Back-to-School Bash

Blessing Boxes

Community Health Fairs and Seminars

Emergency Housing Assistance and Eviction Intervention

Fresh Food and Produce Distribution

Healthy Eyes on the Eastside

Mobile Donation Center

Neighborhood Clean-up and Beautificaion Program

Trunk-or-Treat

What is your availability? *

Please note that we are not open on Sundays.

Monday

Tuesday

Wednesday

Thursday

Friday

Saturday

Virtual

Emegency Contact Name *

In case of emergency, who should we call?

First Name

Last Name

Emergency Contact's Phone *

In case of emergency, how can we reach them?

Country

(###)

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