Name
*
First Name
Last Name
Phone
*
(###)
###
####
Email
*
Address
*
Address 1
Address 2
City
State/Province
Zip/Postal Code
Country
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?
*
Occupation/Job Title
*
Current Employer
*
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:
How many people are in your household, including yourself?
*
1
2
3
4
5
6
7
8
Tell us a little about why you want to be an Ally.
*
What are 1-2 qualities or strengths of yours that would make you a good Ally?
*
What are 1-2 things you hope to learn from Circle Leaders?
*
What would you like a Circle Leader to know about you before being matched?
*
From your perspective, what are the biggest reasons people are in poverty in our community?
*
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?
*
Is anyone else from your household applying to be an Ally?
*
Yes
No
If yes, please specify their name:
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
