No More Excuses:Voting Rights Now! Civil Disobedience participants form
This form is to capture key information regarding your participation in the Fall 2021 Voting Rights Now Actions
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Email *
Please select the date of the action that you are interested in. Please select all that apply.
Please provide your name
Please provide your date of birth.
Please provide your address.
Please provide your phone number.
Please provide the following information for your emergency contact (Name, Phone Number, Relationship)
Do you have any medical conditions or prescriptions we should be aware of? 
Will you need a ride in the DC area after release?
Will you need someone to hold your cell phone bag while risking arrest?
Anything else that you would like to share?
A copy of your responses will be emailed to the address you provided.
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