Community Coalition on Race
Integrated Arts Circles Registration Form

Thank you for your interest in the Integrated Arts Circles Project. Through this project, the Community Coalition on Race hopes to provide you with a recreational experience that develops your artistic side, while connecting you with neighbors from different backgrounds, neighborhoods and races. Your answers to this brief survey will help us to achieve those goals.

Question Title

* 1. Please fill in the following contact information

Name

Address

City/Town

State/Province

ZIP/Postal Code

Email Address

Phone Number

Question Title

* 2. Race (check all that apply):

Black or African American

Hispanic or Latino

Asian or Asian American

American Indian or Alaska Native

Native Hawaiian or other Pacific Islander

White or Caucasian

Another race

Other (please specify)

Question Title

* 3. Age Range

Under 18

18-24

25-34

35-44

45-54

55-64

65+

Community Coalition on Race Integrated Arts Circles Registration Form

Question Title

* 1. Please fill in the following contact information

Question Title

* 2. Race (check all that apply):

Question Title

* 3. Age Range

Community Coalition on Race
Integrated Arts Circles Registration Form