Cultural Equity Learning Community (CELC) Intake Form

Contact and demographic information 🗺

Below you'll find a series of questions that support the CELC team in being able to communicate effectively and best support community members throughout our work together.

Your answers will not be shared with anyone outside of the CELC core facilitation team, please know that we take your privacy very seriously.

Question Title

* 1. Contact Information

Name *

Organizational Affiliation(s)

Address *

City/Town *

State/Province *

ZIP/Postal Code *

Country *

Preferred Email Address *

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* 2. What pronouns do you use? (if any)

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* 3. How do you identify with your lived experience of sexuality? (please select all that apply)

Lesbian

Gay

Bisexual

Pansexual

Asexual

Heterosexual

Queer

Prefer not to answer

Other (please specify)

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* 4. How do you identify with your lived experience of gender? (please select all that apply)

Genderqueer

Nonbinary

Trans

Cisgender

Female

Male

Prefer not to answer

Other (please specify)

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* 5. How do you identify your lived experience of disability? (please select all that apply)

Disabled - mobility / physical

Disabled - spinal cord (SCI)

Disabled - head injuries (TBI)

Disabled - vision

Disabled - hearing

Disabled - cognitive / learning

Disabled - psychological

Disabled - invisible

Able-bodied

Prefer not to answer

Other (please specify)

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* 6. How do you identify your lived experience of race? (please select all that apply)

Black / African American

Indigenous / Native

Person of Color

White

White passing

Multi-racial

Other (please specify)

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* 7. Are you a caregiver?

Yes

Prefer not to answer

Other (please specify)