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Alumnx Info needed for Free Foundwork Account
Thank you for contacting us to receive your free code for a Foundwork profile. Simply provide us with some basic info about your Centrum residency affiliation and you'll receive the code at the end of the survey!
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1.
What year(s) were you, or might you be a Centrum resident? (please list approximate if you can't remember)
(Required.)
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2.
Contact info (we are trying to update our files!)
(Required.)
First Name
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Last Name
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City/Town
State/Province
AL Alabama
AK Alaska
AS American Samoa
AZ Arizona
AR Arkansas
CA California
CO Colorado
CT Connecticut
DE Delaware
DC District of Columbia
FM Federated States of Micronesia
FL Florida
GA Georgia
GU Guam
HI Hawaii
ID Idaho
IL Illinois
IN Indiana
IA Iowa
KS Kansas
KY Kentucky
LA Louisiana
ME Maine
MH Marshall Islands
MD Maryland
MA Massachusetts
MI Michigan
MN Minnesota
MS Mississippi
MO Missouri
MT Montana
NE Nebraska
NV Nevada
NH New Hampshire
NJ New Jersey
NM New Mexico
NY New York
NC North Carolina
ND North Dakota
MP Northern Mariana Islands
OH Ohio
OK Oklahoma
OR Oregon
PW Palau
PA Pennsylvania
PR Puerto Rico
RI Rhode Island
SC South Carolina
SD South Dakota
TN Tennessee
TX Texas
UT Utah
VT Vermont
VI Virgin Islands
VA Virginia
WA Washington
WV West Virginia
WI Wisconsin
WY Wyoming
ZIP/Postal Code
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Country
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Email Address
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3.
Would you be willing to contribute stories about your time at Centrum in preparation for our upcoming 50th Anniversary?
(Required.)
Yes
No
Other (please specify)
4.
What do you think is the most important thing Centrum can do to support residents in today's new COVID-19 reality and moving forward?
Demographics - These questions help us understand more about who our programs are reaching and also help us submit statistics for grant purposes.
5.
How do you describe your gender? (optional)
6.
How do you describe your racial, ethnic, or tribal identity? (optional)
7.
Is there anything else you'd like us to know?
