Name
*
First Name
Last Name
Phone
*
(###)
###
####
Address
*
Address 1
Address 2
City
State/Province
Zip/Postal Code
Country
Email
*
Preferred Method of Contact
*
Phone call
Text
Email
Best days/times to contact
*
Date of Birth
*
MM
DD
YYYY
How would you describe yourself?
*
Male
Female
Prefer to describe
If you prefer to describe, please indicate in the box below. Otherwise skip.
What is your current age?
*
What best describes your race/ethnicity?
*
Black or African American
Hispanic or Latino/a
White
American Indian or Alaska Native
Marshallese or other Pacific Islander
Asian
Middle Eastern
More than one race (specify below)
Other (specify below)
If you selected "More than one race" or "other," please specify here:
Employment Status
*
Full Time
Part Time
Temporary, occasional, or seasonal employment
Stay-at-home parent or homemaker
Not currently employed
If you are currently employed, please specify your current Place of Employment
How many people are in your household, including yourself?
*
1
2
3
4
5
6
7
8
Describe your household.
*
Please tell us how many children you have, age, and gender.
Do you have consistent and reliable childcare during the work week?
*
Yes
No
No children requiring childcare
Are you currently receiving any public assistance benefits?
*
Yes
No
Do you have reliable transportation?
*
Yes
No
Why do you want to be a Circle Leader?
*
Please tell us 2-3 goals you have for yourself, both personally and professionally.
*
What do you see as the top barriers holding you back from achieving your goals?
*
What are 2-3 words you would use to describe yourself and WHY?
*
What other organizations, if any, are you already involved in?
*
This could be community, social, faith-based, or other groups.
How did you hear about Circles NWA?
*
Circles currently meets Wednesday from 6:00 p.m. - 8:00 p.m. in Fayetteville. Please confirm this will work with your schedule. A meal and childcare are provided each week.
*
Yes
No
