We appreciate your input so we can build a 21 Day Racial Equity & Social Justice Challenge experience that is supportive and beneficial for all participants. Your answers will remain anonymous and confidential. We will share impact measures after the Challenge with aggregated data to demonstrate reach, demographics, and outcomes. 

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* 1. FULL NAME 

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* 2. ZIP CODE

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* 3. E-MAIL ADDRESS

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* 4. HOW OLD ARE YOU?

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* 5. HOW DO YOU DEFINE YOUR GENDER IDENTITY?

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* 6. WHAT RACE DO YOU IDENTIFY WITH?

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* 8. ARE YOU PARTICIPATING IN THIS CHALLENGE AS AN INDIVIDUAL OR WITH AN ORGANIZATION?

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* 9. HOW DID YOU HEAR ABOUT YWCA GLENDALE'S 21 DAY RACIAL EQUITY & SOCIAL JUSTICE CHALLENGE?

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* 10. WHAT INSPIRED YOU TO TAKE THIS CHALLENGE?

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* 11. WHAT ARE YOUR GOALS AND INTENTIONS FOR YWCA GLENDALE'S 21 DAY RACIAL EQUITY & SOCIAL JUSTICE CHALLENGE?

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* 12. HOW WILL YOU STAY MOTIVATED TO COMPLETE THIS CHALLENGE?

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* 13. IMAGINE YOU HAVE COMPLETED THE FINAL DAY OF THE CHALLENGE. WHAT WILL YOU HAVE ACCOMPLISHED THROUGH YOUR PARTICIPATION? WHAT WILL BE DIFFERENT?

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* 14. HOW CAN YWCA GLENDALE SUPPORT YOU THROUGH THIS CHALLENGE?

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