VA BLOC Builders
Please fill out this form to join VA BLOC and others in the Hampton Roads Community who want to make a difference!
We are building empowered communities and we need your help!
First Name
Your answer
Last Name
Your answer
Street Address
Your answer
City
Your answer
State
Your answer
Zip Code
Your answer
Phone Number
Your answer
Email Address
Your answer
What is your age range?
Voting Precinct
Your answer
Are you registered to vote?
Please select your top three (3) concerns in your community:
Required
For you to attend a meeting or event, what would be the best times? Check all that apply.
Required
How did you hear about VA-BLOC?
Required
Submit
Never submit passwords through Google Forms.
This form was created inside of New Virginia Majority. Report Abuse - Terms of Service - Additional Terms