Thank you for your participation in CCEJ's United in Dialogue: A Community Conversation Against Hate Event. Please take a few minutes to answer a few questions about your registration. All information obtained from this survey will remain confidential. Any information obtained will be presented only as a summary of all persons responding. 

Please note: The zoom link for the event will be provided to all enrolled participants the week before the event. 

If there are any questions or concerns about this form, please contact Healing Harms Program Coordinator Alejandro "Ali" Haezaert-House at ahaezaert@cacej.org or 562.435.8184 x113.

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* Contact Information

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* Is this your first time participating in a circle dialogue?

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* Gender Identity:

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* Age:

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* Race/ethnicity Identity (please list all):

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* Languages you speak:

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* Annual household income:

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* How did you hear about this event?

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* What are you hoping to get out of the event?

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* Are there any accessibility needs or accommodations you need to feel comfortable during your time with us?

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