DEI Committee Application

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* 1. Name

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* 2. Primary Area of Focus/Practice

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* 3. Gender

Female

Male

Non-binary

Prefer not to answer

Other (please specify)

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* 4. What is your race/ethnicity?

White or Caucasian

Black or African American

Hispanic or Latinx

Asian or Asian American

American Indian or Native American

Native Hawaiian or other Pacific Islander

Middle Eastern

Prefer not to say

Other (please specify)

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* 5. Are you a member of the Lesbian, Gay, Bisexual, Transgender, Queer (LGBTQ+) community?

Yes

Prefer not to say

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* 6. Age group

18-24

25-34

35-44

45-54

55-64

65+

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* 7. Geographic location

Southeast Michigan

Thumb region

Central Michigan

Southwest Michigan

West Michigan

Northern Michigan (lower Peninsula)

Upper Peninsula

DEI Committee Application

Question Title

* 1. Name

Question Title

* 2. Primary Area of Focus/Practice

Question Title

* 3. Gender

Question Title

* 4. What is your race/ethnicity?

Question Title

* 5. Are you a member of the Lesbian, Gay, Bisexual, Transgender, Queer (LGBTQ+) community?

Question Title

* 6. Age group

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* 7. Geographic location

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* 8. Please tell us about any experience you have serving on a DEI Committee or initiative.

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* 9. Please tell us (in 500 words or less) why you're interested in joining the DEI Committee.

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* 10. Please tell us (in 500 words or less) why you'd be a valuable member of this committee.