Your name:
Street Address:
City: State: Zip:
Email: Phone Number: ( ) -
Will you need childcare in order to attend Saturday meetings? Yes No
If yes, how many children and what are their ages:
What is your primary language?
If other than English, do you speak English well? Yes No
Are you currently receiving any kind of public assistance (food stamps,
Medicaid, Section 8, TANF, SafetyNet)?
What do you hope to get out of these meetings?
Would you like to suggest a discussion topic?
What are your thoughts about, or interests in, the social service system?
OPTIONAL . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Group diversity is very important to us. To help us maintain a balanced group, please provide your:
Race/Ethnicity and age
Are you involved with any community organizations? Yes No
If so, which?
How has your experience been with the social service system so far?
