Sign-up form: West Burlington Community Conversation

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Sign-up form: West Burlington Community Conversation – Monday, July 11th: 6 - 8pm

Impact Alamance has partnered with The Harwood Institute for Public Innovation to: (1) generate community-led transformation on concerns that matter to people and (2) strengthen Alamance County’s civic culture so the community can take effective, sustainable action.

Conversations are taking place in various towns and neighborhoods across Alamance County, and now we are eager to engage West Burlington residents in a conversation scheduled for Monday, July 11th at 6pm. All conversation participants will receive a $25 gift card for being a part of the conversation.

Thank you so much for your willingness to participate. Before this conversation, we need to collect the demographic information of participants.

This information is for The Harwood Institute's purpose only; it is only being collected to ensure that our conversation accurately represents the make-up of the community. Your information will not be shared with other conversation participants and will not be shared publicly in any way.

Name *

Phone Number *

Email address (if you have one) *

Occupation *

Are you available to participate in the conversation taking place on Monday, July 11th at 6pm ET at the Cutting Board restaurant? *

Yes

Are you available to get your own transportation for the conversation? *

Yes

Would you like to receive a $25 gift card for participating? *

Yes

What neighborhood do you live in? *

Gender *

Female

Male

Transgender Female

Transgender Male

Non-binary

Prefer not to identify

Other:

Age *

Race *

Asian/Asian American

Black of African American

Hispanic or Latino/a

Native Hawaiian or other Pacific Islander

Native American or Indigenous

White

Multi-Racial (specify in notes)

Prefer not to say

Highest Education Level *

Some high school

High school GED

Technical Certificate/Associate's Degree

Some College

Bachelor's Degree

Higher Degree

Prefer not to say

Number of people in your household (including you): *

Household income *

$0 - 24,999

$25K - 49,999

$50K - 74,999

$75K - 99,999

$100K +

Prefer not to say

Would you like a copy of the Alamance County's community report sent to your email once it is published? *

Yes

Would you like to be added to The Harwood Institute's email list? *

Yes

Any notes, thoughts, questions or comments? *

Submit

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