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Massachusetts Collaborative for Action, Leadership, and Learning 3- Positive Youth Development
We appreciate your time in completing the registration. Your participation is very important to us.
1.
First name and Last Name Initial
2.
At what email address would you like to be contacted?
3.
What is your gender?
Female
Male
Other (please specify)
4.
What is your sexual orientation?
Bisexual
Gay/Lesbian
Heterosexual or straight
None of the above, please specify
5.
What is your race or ethnicity?
Asian
Black or African American
Hispanic or Latino
Middle Eastern or North African
Multiracial or Multiethnic
Native American or Alaska Native
Native Hawaiian or other Pacific Islander
White
Another race or ethnicity, please describe below
Self-describe below:
6.
What is your primary language?
7.
Choose all that apply to you
Parent/ Caregiver
Teacher/ School Administrator
Youth (middle school)
Youth (High School)
Healthcare/ Mental health provider
Youth Serving Agencies
Faith based organizations
Public Safety
Media
Neighborhood and Cultural associations
Board of Health
Local Business Owner
Public Health agency
Other (please specify)
8.
In what town/city do you reside in?
Worcester
Grafton
Millbury
Shrewsbury
Other (please specify)
9.
In what town/city do you work or attend school?
Worcester
Grafton
Millbury
Shrewsbury
Other (please specify)
10.
What do you think are the needs of the youth in your community?
11.
What practices are currently in place that are negatively or positively affecting the youth in your community?
12.
Do you have any suggestions of what can be done to improve the wellbeing of the youth in your community?
13.
What is your engagement preference? (Choose all that apply)
Focus group
One-on-one Interview
Thank you for participating. If you do not hear from us within 7 days kindly send us an email on NakijobaJ@worcesterma.gov or call us at 857-243-1493