Community Leader Application Survey

1.Why are you interested in being a community leader in this group?(Required.)

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)

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

5.How many people are in your household?

6.Do you need childcare for meetings?

Yes

No

If so, please list the age of your children.

7.Do you need interpretation?

Yes

No

If yes, what language?

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