Exit ENCOUNTER Charlotte Application--Spring 2019 Question Title * 1. Name First Name Last Name Prefer to be called Question Title * 2. Year of birth (enter 4-digit birth year; for example, 1976) Question Title * 3. Gender Question Title * 4. Race/Ethnicity Question Title * 5. Headshot Upload your photo here. DOCX, DOC, JPEG, GIF, JPG, PDF, PNG file types only. Choose File Choose File No file chosen Remove File Upload your photo here. Question Title * 6. Current Employer Question Title * 7. Occupation/Title Question Title * 8. Home Contact Information Address * Address 2 City/Town * State/Province * -- select state -- AL AlabamaAK AlaskaAS American SamoaAZ ArizonaAR ArkansasCA CaliforniaCO ColoradoCT ConnecticutDE DelawareDC District of ColumbiaFM Federated States of MicronesiaFL FloridaGA GeorgiaGU GuamHI HawaiiID IdahoIL IllinoisIN IndianaIA IowaKS KansasKY KentuckyLA LouisianaME MaineMH Marshall IslandsMD MarylandMA MassachusettsMI MichiganMN MinnesotaMS MississippiMO MissouriMT MontanaNE NebraskaNV NevadaNH New HampshireNJ New JerseyNM New MexicoNY New YorkNC North CarolinaND North DakotaMP Northern Mariana IslandsOH OhioOK OklahomaOR OregonPW PalauPA PennsylvaniaPR Puerto RicoRI Rhode IslandSC South CarolinaSD South DakotaTN TennesseeTX TexasUT UtahVT VermontVI Virgin IslandsVA VirginiaWA WashingtonWV West VirginiaWI WisconsinWY Wyoming ZIP/Postal Code * Email Address * Cell Phone Number * Question Title * 9. Preferred Contact Information (if different from above) Address Address 2 City/Town State/Province -- select state -- AL AlabamaAK AlaskaAS American SamoaAZ ArizonaAR ArkansasCA CaliforniaCO ColoradoCT ConnecticutDE DelawareDC District of ColumbiaFM Federated States of MicronesiaFL FloridaGA GeorgiaGU GuamHI HawaiiID IdahoIL IllinoisIN IndianaIA IowaKS KansasKY KentuckyLA LouisianaME MaineMH Marshall IslandsMD MarylandMA MassachusettsMI MichiganMN MinnesotaMS MississippiMO MissouriMT MontanaNE NebraskaNV NevadaNH New HampshireNJ New JerseyNM New MexicoNY New YorkNC North CarolinaND North DakotaMP Northern Mariana IslandsOH OhioOK OklahomaOR OregonPW PalauPA PennsylvaniaPR Puerto RicoRI Rhode IslandSC South CarolinaSD South DakotaTN TennesseeTX TexasUT UtahVT VermontVI Virgin IslandsVA VirginiaWA WashingtonWV West VirginiaWI WisconsinWY Wyoming ZIP/Postal Code Email Address Phone Number Question Title * 10. Emergency Medical Contact Person Name * Relationship to you * Mobile Phone Number Other Phone Number * Question Title * 11. To ensure accurate application of your payment, please note below any other name or entity that may be associated with your ENCOUNTER tuition. If none, please put N/A. Question Title * 12. I would be interested in learning about scholarship opportunities for ENCOUNTER. Yes. No. Question Title * 13. How did you hear about ENCOUNTER Charlotte? Question Title * 14. How long have you lived Charlotte? Question Title * 15. Where did you previously live? Question Title * 16. Why did you relocate to Charlotte? Question Title * 17. What are the top three Charlotte leadership areas you would like to know about? 1st Leadership Area 2nd Leadership Area 3rd Leadership Area Question Title * 18. What are your current (or previous) volunteer interests? 1st Volunteer Interest 2nd Volunteer Interest 3rd Volunteer Interest Question Title * 19. Do you have any food allergies or dietary restrictions? No. Yes (please specify below) Details of your allergy or restriction: Register