Member Interest Form

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Email *

How did you hear out about Nation Outside? *

Facebook

Twitter

Instagram

YouTube

Friend or Family

Social Service

Attended a Nation Outside Event

Other:

Required

First Name: *

Last Name: *

Birthdate: *

YYYY

Phone Number: *

Zip Code: *

Gender *

Male

Female

Nonbinary

I do not wish to answer

Other:

Race: *

White (A person having origins in any of the original peoples of Europe, the Middle East, or North African)

Black or African American (A person having origins in any of the black racial groups of Africa)

American Indian or Alaska Native (A person having origins in any of the original peoples of North and South America including Central America)

Asian (A person having origins in any of the original peoples of the Far East, Southeast Asia, or the Indian subcontinent including, for example, Cambodia, China, India, Japan, Korea, Malaysia, Pakistan, the Philippine Islands, Thailand, and Vietnam)

Native Hawaiian or Other Pacific Islander (A person having origins in any of the original peoples of Hawaii, Guam, Samoa, or other Pacific Islands)

I do not wish to answer

Other:

Ethnicity: *

Hispanic or Latino (A person of Cuban, Mexican, Chicano, Puerto Rican, South or Central American or other Spanish culture or origin, regardless of race)

Not Hispanic or Latino

I do not wish to answer

Chapter you are interested in joining *

Detroit

Kalamazoo

Grand Rapids

Lansing

Oakland

Washtenaw

Native American

Women's

Jackson

Flint

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Preferred form of communication: *

Text

Phone Call

Are you registered to vote? *

Yes

Unsure

If registered to vote, check all that apply: *

Voted in the past

Plan to vote in the future

Never voted

Do not plan to vote in the future

Not applicable, not registered

Required

Are you a recipient or eligible to receive Medicaid, SNAP, Rental Assistance and/ or Utility Assistance? *

Yes

Unsure

I do not wish to answer

What is your employment status? *

Employed

Homemaker

Student

Not Employed

I do not wish to answer

Other:

Are you interested in any of the following? Check all that apply. *

Policy advocacy

Voting Rights

Housing rights

Mentorship opportunities

Training

Professional development

Employment readiness class

Community Building

Events and Social Activities

Other:

Required

Is there a specific way we can help you? *

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