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Contact 1
First Name
Last Name
Birth Date
Street Address
City
Postal Code
State/Province
Alabama
Alaska
American Samoa
Arizona
Arkansas
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Guam
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Northern Mariana Islands
Ohio
Oklahoma
Oregon
Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
United States Minor Outlying Islands
Utah
Vermont
Virgin Islands
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Phone Number
Email
Screen Name
Screen Name 2
Screen Name 3
Demographics
Gender Pronouns
They/Them
She/Her
He/His
Ethnicity / Race
Asian or Pacific Islander
Black or African-American
Hispanic or Latino
Middle Eastern
Native American or American Indian
White
Other
Decline to state
Multiethnic/Multiracial
Select all that apply
Interests
Issues Interest
Immigrant Rights
Economic Justice
Workers' Rights
Environmental Justice
Women's Rights
Reproductive Justice
LGBTQ Rights
Young Families' Rights
Racial Justice
Housing
Housing Justice
What issues has this person expressed interest in?
Questions
What are your Reproductive Justice dreams for the Central Valley?
What would you like to get out of this new program?
What would you like to bring to this program?
This program will take an estimated time commitment of 20 hours a month with bi-weekly meetings on Thursdays from 6-8pm. Are you willing to make this time commitment?
Yes!
No, not at this time. How else can I support?
Yes, with support/adjustment. Lets chat more.
This program will have events, assignments, networking goals and group goals. Can you commit tackling goals outside of bi-weekly meetings?
Yes! I know how to self manage my time and goals.
I'm not sure. Can you tell me more?
Yes, with support, tools and help I can manage.
Any access opportunities that will help you participate in this community?
Mental, physical or emotional?