My Voice Our Story Interest Form

What is your preferred name? *

What is the best phone number to reach you?

What is the best email to reach you? *

Which county do you live in? *

What races and ethnic groups are a part of your personal identity? Select all that apply *

African-American / Black

Asian-American / Asian / Pacific Islander / Hawaiian Native

Caucasian-American / White

Hispanic-American / Hispanic

Native American / American Indian / Alaska Native

Other (please explain) Other (please explain)

What languages do you use in your daily life? *

English

Spanish

Other (please explain) Other (please explain)

What gender(s) are a part of your personal identity? *

Do you identify as a part of the LGBTQAI+ community (privately or publicly)? *

Yes

No

What is your age range? *

What storytelling activities do you want to join? *

	First Choice	Also Interested	Not Interetsed
Oration (create a 5min spoken story)	First Choice	Also Interested	Not Interetsed
Writing (create a poem, 5min skit, or short-story)	First Choice	Also Interested	Not Interetsed
Photography (create a photographic story with a 5min explanation)	First Choice	Also Interested	Not Interetsed
Video (create a 5min youtube, tiktok, or IGlive video)	First Choice	Also Interested	Not Interetsed
Fiche (create collage, decollage, decoupage stories)	First Choice	Also Interested	Not Interetsed

Male	Female	Nonbinary
Trans	Gender Non-conforming	Other (please explain) Other (please explain)

13 years old or younger	13-17 years old	18-24 years old
25-34 years old	35-49 years old	50 years old and up