Name *

First Name

Last Name

Phone

(###)

###

####

Are you Hispanic or Latino?

Yes, I am of Hispanic, Latino, or Spanish origin.

No, I am NOT of Hispanic, Latino, or Spanish origin.

Race

Select one or more

American Indian or Alaska Native: a person having origins in any of the original peoples of North and South America (including Central America) and who maintains tribal affiliation or community attachment.

Asian: a person having origins in any of the original peoples of the Far East, Southeast Asia, or the Indian subcontinent including, for example, Cambodia, China, India, Japan, Korea, Malaysia, Pakistan, the Philippine Islands, Thailand, and Vietnam.

Black or African American: a person having origins in any of the Black racial groups of Africa.

Native Hawaiian or other Pacific Islander: a person having origins in any of the original peoples of Hawaii, Guam, Samoa, or other Pacific Islands.

White: a person having origins in any of the original peoples of Europe, the Middle East, or North Africa.

Date *

Todays date

MM

DD

YYYY

Have you been fired or asked to resign from a paid or volunteer position because of any kind of harassment or physical violence? *

Yes

No

Have you ever been convicted of a criminal offense? *

Yes

No

Have you ever been charged with neglect, abuse, or assault?

Yes

No

Other than the above, is there any fact involving you or your background that would call into question your participation in You’re With Us!?

Yes

No

Date *

Todays date

MM

DD

YYYY