Answering the following questions will help us bring together a diverse group of participants. If you are not comfortable with answering any question, please feel free to skip that question.  The following questions are voluntary. This information will only be shared with the One Fort Worth: City of Fort Worth Race & Culture Task Force Co-Chairs and the staff assisting with the meetings. However, the information provided on this form may be subject to release to the public under the Texas Public Information Act.   

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* 1. Have you been asked to participate in a Community Conversation?  

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* 2. If so, what organization invited you to participate?

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* 3. Name

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* 4. Address

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* 5. Phone

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* 6. Email

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* 7. What is your age? 

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* 8. Please select the race or ethnic group you identify with:  Check all that apply 

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* 9. What is the highest degree or level of school you have completed?  

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* 10. What is your marital status? 

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* 11. Are you currently?  Circle one 

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* 12. How would you identify your sexual orientation?  Circle one 

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* 13. How would you identify your gender?  Choose one 

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* 14. Religion

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* 15. Political affiliation

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* 16. How would you describe where you have lived (in years)?  Write the number for each.

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* 17. Are you requesting assistance in order to participate in the Community Conversations? 

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* 18. Why do you want to participate in the Community Conversations?

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* 19. What are your hopes for these Community Conversations?

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* 20. Have your views on Race and Culture changed through the years?  If so, please describe how.

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* 21. Other comments:

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