MIRA's New American Changemakers - Interest Form
Please fill out this form if you would like to be considered for participation in MIRA's New American Changemakers program. Participants will attend a series of 4 online workshops on topics related to understanding our local, state, and federal government structures, learning about policies impacting immigrants and refugees, voter registration and civic engagement, and gaining skills to advocate to policymakers.

You can read about the program details here: https://www.miracoalition.org/citizenship/changemakers/

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What month and year did you become a citizen? *
First and Last Name  *
Country of Origin  *
What language do you speak at home? *
Phone Number
*
As part of the selection process, we would like to schedule brief (15 minute) phone calls to learn more about your interest in the program. When is your availability for a call? *
Required
Email *
Your full mailing address (street, apartment number, city, and zip code) where you would like to receive the stipend check if selected for participation.
 *
Age *
Pronouns you want people to use when speaking about you
Clear selection
Do you have access to a computer with Zoom? (The program will be held via Zoom. Access to a computer is not required, but helpful).
 *
Do you know how to use Zoom?
 *
Tell us about one way your life has changed since becoming a US citizen. (350 character response maximum) *
Please describe any ways in which you are active in your community (for example, volunteering, involved in your children's school, etc) (350 character response maximum)
 *
Why do you want to increase your knowledge and skills around civic engagement (ways to become involved in your community and making changes)? (350 character response maximum) *
Can you commit to attending all 4 workshops by Zoom AND the civic engagement activity?

The 4 online workshops are on:
Tuesday, September 5, 2023 from 6pm-7:30pm
Tuesday, September 12, 2023 from 6pm-7:30pm
Tuesday, September 19, 2023 from 6pm-7:30pm
Tuesday, September 26, 2023 from 6pm-7:30pm

The civic engagement event will be an in-person activity. 
 *
If you can't attend, what days work better for you?
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