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Safer Together Interest Form
Yes, I'd like to know more about upcoming community discussions and other activities to be part of making my neighborhood and community safer.
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* Indicates required question
Name
*
Your answer
Phone Number
Your answer
Can we text this number?
Yes
No
Clear selection
Email Address
Your answer
Area Map
We are working with a community initiative that focuses on a specific region of East Winston. Do you live in the area indicated in blue on the map above?
*
Yes
No, but I attend church/worship in this area
No, but I work in this area
No, but I go to school (or my kids go to school) in this area
I live in an area adjacent to these neighborhoods
No
Other:
If yes, which neighborhood do you live in?
Your answer
What topics, ideas or concerns would you like to see addressed in your community?
Your answer
Demographics
For our program reporting
How do you describe yourself
Male
Female
Non-binary
Other:
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How do you describe yourself?
White
Hispanic or Latinx
Black or African-American
Multi-racial
Other:
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Age Range
13 or under
14-17
18-24
25-49
50-64
65-74
75-84
85 +
Clear selection
What is your zip code?
Your answer
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