Member Info Form

Thank you for your interest in becoming a member with The Audre Lorde Project (ALP). We are always in search of community members to help us accomplish our mission.

Please fill out this member info form. Once received, an interview will be arranged. The information on this form will only be used in connection with the work of The Audre Lorde Project.
It will only be accessible to designated staff and members.

Contact Info

Name (First and Last): *

Street Address:

City:

State:

Zip:

Home Phone:

Work Phone:

Email:

May we call during business hours?:

yes

Should we leave confidential messages at your home and work?:

yes

Emergency Contact Name:

Emergency Contact Home Phone:

Emergency Contact Work Phone:

Emergency Contact's relationship to you:

Background

What is your occupation?:

Briefly describe previous or current volunteer work that you've done:

Please list any licenses or clinical certifications that you hold:

List the languages that you speak and indicate your level of proficiency:

For each language, let us know if it is your native tongue or a second language and whether you are a translator, teacher, or interpreter of that language.

Is there anything else you'd like us to know?:

Demographic Info

The following information will be used only for statistical purposes.

Country of birth:

Date of birth:

Gender identity:

For example: female, trans man, etc.

Sexual orientation:

For example: lesbian, bisexual, queer, etc.

CAPTCHA

This question is for testing whether you are a human visitor and to prevent automated spam submissions.

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