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* 1. name

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* 2. preferred pronouns

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* 3. What is your racial or ethnic identity? 

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* 4. Please use this space to tell us anything else you want us to know about your identity.

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* 5. Please check a category that best describes your field

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* 6. If you are a service provider, which populations/issues do you serve?

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* 7. organization name (or resident)

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* 8. email

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* 9. phone number

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* 10. role/title

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* 11. What are you hoping to get out of your participation in the CHNA 17 Racial Equity Learning Community?

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* 12. How would you describe your racial equity experience to date?

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* 13. What has been your involvement in CHNA 17 to date?

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* 14. Have you participated in CHNA 17's Racial Equity Learning Community before?  If yes, when?

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* 15. Are you interested in being paired with someone from the group to support accountability?

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* 16. If you are interested in being paired with someone, what is the best way to reach you?

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* 17. Do you need any special accomodations?

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* 18. Please use this space to tell us anything else we should know.  Thanks!

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