Survivors 4 Justice Reform: Become a State/County/Provincial Rep
Once you fill out this form, we will create a channel specific to your state/province in the discord and reach out to you with next steps. Note: We recommend this role for folks that are comfortable advocating publicly rather than anonymously. The state/provincial rep will moderate their chapter's channel in the discord, they may amplify the network within their state/province, they may want to host in-person or virtual meetings/actions specifically for local chapter members (no minimum requirements, as we recognize this work is currently on a voluntary basis. Our intention here is to bring voices together, to build community & to host this platform to support local organizing).
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Name & Pronouns: *
Email: *
Your state/county/province + country: *
Social Media Handle *
Why do you want to become a state/provincial representative for Survivors 4 Justice Reform? *
What potential visions do you have for your state/province S4JR chapter? (ie. hosting in-person meetups, building local community, quarterly meetings, working together to address a specific policy, etc.) 
If you'd prefer to share this role with another individual (co-lead) let us know! *
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