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Advanced Academy Application
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Contact 1
First Name
Last Name
Birth Date
Street Address
City
Postal Code
State/Province
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?