Community Leader Application Survey

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* 1. Why are you interested in being a community leader in this group?

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* 2. What communities are you part of? And/or what life experiences do you have? Please check as many boxes as apply to you.

I (or someone in my immediate family) have a chronic disease

I (or someone in my immediate family) have used the mental health system

I (or someone in my immediate family) have experienced substance abuse

I (or someone in my immediate family) speak a language other than English as my primary language

I (or someone in my immediate family) come from or represent a culture different from majority culture

I (or someone in my immediate family) practice a religion different from majority Christian religion

I (or someone in my immediate family) make an income that makes it hard to make ends meet

I (or someone in my immediate family) struggle with affordable, safe and/or stable housing

I (or someone in my immediate family) struggle with transportation

I (or someone in my immediate family) have knowledge or experience being disabled

I (or someone in my immediate family) am over the age of 60

Other (please specify)

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* 3. What community issues are important to you?

Mental Health

Housing

Transportation

Lack of Social Support

Substance Abuse

Preventative Health

Other (please specify)

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* 4. What is your monthly income? (Used for demographics for grant purposes)

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* 5. How many people are in your household?

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* 6. Do you need childcare for meetings?

Yes

If so, please list the age of your children.

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* 7. Do you need interpretation?

Yes

If yes, what language?

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* 8. How old are you?

16-17

18-24

25-34

35-44

45-54

55-59

60-74

75+

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* 9. Please give us your contact information so we may call you for next steps.

Name

Company

Address

Address 2

City/Town

State/Province

ZIP/Postal Code

Country

Email Address

Phone Number