JavaScript isn't enabled in your browser, so this file can't be opened. Enable and reload.
Raleigh #BlackSummer19 Teach-In: Registration Form
#BlackSummer19 Teach-In
Friday, September 13, 2019
4021 Carya Dr., Raleigh, NC 27610
4:30pm to 7:00pm
Light refreshments will be provided
Sign in to Google
to save your progress.
Learn more
* Indicates required question
Email
*
Your email
Name
*
Your answer
Preferred Pronouns
*
She, Her, Hers
He, Him, His
They/Them/Theirs
Other:
Organization/Agency/School Affiliation
Your answer
Age
12 and Under
13- 17
18- 25
26-35
36- 45
46- 55
56- 65
65 and Up
Clear selection
Phone
*
Your answer
Zipcode
*
Your answer
Race
*
African American/Black
Asian
Indigenous/American Indian
Native Hawaiian/Pacific Islander
White
Ethnicity
*
Not Hispanic or Latinx
Hispanic, Latinx or Spanish Origin
Other:
Sex
*
Male
Female
Non-Binary
Prefer Not to Say
Other:
I voluntarily give permission for Youth Empowered Solutions to use photographs, videotapes, audiotapes and basic information about me to illustrate its programs and services without providing compensation.
*
Yes
No
I want to be added to your mailing list to receive updates, newsletters and other information about yourprograms and services.
*
Yes
No
Do you have any dietary restrictions?
*
Yes
No
If so, what are they?
Your answer
How Did You Hear About This Event?
*
Word of Mouth
Social Media
YES! Newsletter
Printed Flyer
Digital Flyer
Traditional Media (TV News, Newspaper, Radio etc.)
Other:
Required
Send me a copy of my responses.
Submit
Page 1 of 1
Clear form
Never submit passwords through Google Forms.
reCAPTCHA
Privacy
Terms
This form was created inside of Youth Empowered Solutions - YES!.
Report Abuse
Forms
