Civic Influencers Application

Name *

First Name

Last Name

Legal Name (if different)

First Name

Last Name

Date of Birth *

MM

DD

YYYY

Phone Number *

(###)

###

####

Current Mailing Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Are you a veteran or currently serving in the U.S. military? *

Yes

No

Wish not to answer

Are you legally able to work in the U.S.? *

Yes

No

What term(s) are you applying for? *

Select any and all that you would potentially like to be a part of. (Exact term start and end dates may be subject to change)

Fall 24', September 16th - December 13th

N/A

I identify as: *

(Select all that apply)

African American

Asian

Asian American

Black African

Latino/Latina/Latinx/Hispanic

Middle Eastern

Mixed Race / Multi-race

Native American / Alaskan Native

Pacific Islander / Native Hawaiian

White / European

Prefer not to answer

Prefer to self-describe

What is your gender? *

Woman

Man

Nonbinary

Agender

Gender fluid

Gender queer

Prefer not to answer

Prefer to self describe

What are your pronouns? *

she/her/hers

he/him/his

they/them/theirs

other/ask me

Are you a member of any of the following communities? *

(Select all that apply)

LGBTQ+

People with disabilities

Neurodiverse

First generation college student

First generation American

English as a second language

Bi- or Multilingual

Food or housing insecure

Foster youth

Are you currently enrolled in college? *

(Either part-time or full-time)

Yes

No

Do you identify as a first-generation student?

(i.e., your parents/guardians did not attend college or graduate from college in the United States)

Yes

No

Prefer not to answer

I don't know

What is your current college enrollment status?

First-Year

Sophomore

Junior

Senior

Graduate

Prefer not to answer

I don't know

How did you hear about this opportunity?

Civic Influencers Website

Club or Organization

Current/Previous Civic Influencer

Email Blast

Friend

Job posting/Handshake

Social media

Staff or Faculty Member