Skip to content
Umoja Alumni Association Registration Form
1.
First Name
2.
Last Name
3.
Preferred Name
4.
Email Address
5.
Phone Number
6.
Mailing Address
7.
City
8.
State/Province
9.
Zip Code
10.
Country
11.
Preferred Method of Contact
Email
Phone
Text
Social Media
Mail
12.
Social Media Handles
13.
Institution(s) where you participated in Umoja
14.
Years Participated
15.
Last Year in Program
16.
Umoja Coordinator (Past)
17.
Degrees Earned
AA
AS
BA
BS
MA
MS
PhD
JD
EdD
Certificate
Other (please specify)
18.
Institutions Attended Post-Umoja
19.
Institution Type
Community College
CSU
UC
Private
Out-of-State
HBCU
International
20.
Are you currently a student?
Yes
No
21.
Current Institution Name
22.
Current Major/Field of Study
23.
Degrees Currently Pursuing
AA
AS
BA
BS
MA
MS
PhD
JD
EdD
Certificate
Other
24.
Degree Status
In Progress
Completed
Withdrew
Transferred
25.
Expected Graduation Year
26.
Current Employment Status
Employed Full-Time
Employed Part-Time
Self-Employed
Unemployed
Student
Retired
27.
Current Occupation
28.
Current Industry
Education
Health
Tech
Business
Arts
Gov/Policy
STEM
Nonprofit
Other
29.
Current Employer
30.
Job Title
31.
City/State of Employment
32.
LinkedIn Profile
33.
Interested in PROVIDING Mentoring?
Yes
No
34.
Interested in RECEIVING Mentoring?
Yes
No
35.
Interested in Speaking at Events?
Yes
No
36.
Interested in Alumni Newsletter?
Yes
No
37.
Are you interested in taking a leadership role by joining the Umoja Alumni Advisory Council?
Yes
No
Maybe
38.
Please share why you are interested in joining the Umoja Alumni Advisory Council.
39.
Please describe your leadership experience working with a non-profit Board, an Advisory Council, or student leadership positions.