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It is important to identify members who are currently active in the community. This information will help UESF design an effective outreach plan as we build community support for the work we do in our schools.

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* 1. First Name

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* 2. Last Name

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* 3. School/Work Site

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* 4. Email

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* 5. Phone

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* 6. Please list any national, state and/or local organizations that you are currently involved in (e.g., NAACP, Sierra Club).

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* 7. Please list any local and/or neighborhood associations or community organizations that you are currently involved in (e.g., PTA, Tenants Union, Homeowners Association, Neighborhood Association, LGBT group).

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* 8. Please list any Faith-based organizations that you are currently involved in.

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* 9. Please list any business or professional organizations that you are currently involved in (e.g., Chamber of Commerce).

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* 10. Please list any other groups or organizations that you are currently involved in.

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* 11. Would you be interested in becoming more involved in community outreach activities?

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* 12. Do you have any comments or suggestions?

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