Secret Shopper Interest Form

JavaScript isn't enabled in your browser, so this file can't be opened. Enable and reload.

Change Today, Change Tomorrow is relying on members of the community to survey 100 local, white-owned businesses to asses their implicit biases, micro-aggressions, and even blatant overt racism. Please fill the form out below if you are interested in participating in this 2021 program.

Your Name *

Your Email Address *

Your Cell Phone Number *

Your Race *

Black

American Indian or Alaska Native

Asian

Native Hawaiian or Other Pacific Islander

White

Two or More Races

Your Age *

18-24

25-35

36-47

48-60

60+

Other:

Thank You!

We will contact you within one week via email with a store assignment and follow up instructions.

Submit

Clear form

Never submit passwords through Google Forms.

This form was created inside of Taylor Ryan. Report Abuse

Forms