Warrior Moms - Membership
We would like to know more about you and understand how we can grow together to seek clean air for all, especially our children.

It is our principle to respect each member's privacy. We keep all information private and do not share it with any third party without the members' consent.

The information collected from this form will go into our database for record-keeping purposes.
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Name *
What city do you currently live in? *
At what email address would you like to be contacted? *
What is your age? *
What do you do? *
Required
Are you a member of any network/local group/citizen forum? Please mention it here. *
How many children are you parent or guardian for and live in your household? Tell us their ages as well.
Do any of your children/self/family members suffer from diseases triggered by polluted/poor quality air? It could be short/long term, episodic. Also, it may have happened to your child at a young age but not anymore. *
Required
You can give us as much detail as possible here
What are your expectations from being a part of Warrior Moms? And which personal goals for environmental change do you think you can achieve by becoming a Warrior Mom? *
What are your skills which you can/would like to contribute to the growth and campaigns of Warrior Moms? Any ideas/suggestions are also welcome. *
How many hours a week can you dedicate to Warrior Moms?
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How would you like to be contacted for updates and news from Warrior Moms? *
Would you be interested in joining a monthly sharing circle? *
Your phone number (It is our principle to respect each member's privacy. We keep all information private and do not share it with any third party without the members' consent. Your number will go into our database for record-keeping purposes)
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