Greetings, Circles of Change Participants!
Thank you for agreeing to play an active role in our Circles of Change. This project could not happen without your commitment to equity, diversity and inclusivity to make our community a better place for everyone.
The success of this project is dependent upon having a diverse group of individuals who are willing to share and exchange information that will lead to action plans. As a result, as part of your registration, we ask you to provide demographic information that will help us place you within a diverse cohort group. All information will be kept confidential and will not be shared publicly. If you have any questions or concerns, please contact Dr. Audrey Robinson at
Please complete the registration form below. Once we have received your completed registration form, an email confirmation and options for session dates and times will be sent to you.
We look forward to you being a part of the Circles of Change Dialogues and Action Teams.
First and last name
61 and over
To which racial or ethnic group(s) do you most identify?
African American (non-Hispanic)
Latino or Hispanic
Native American or Aleut
City of Eau Claire
Eau Claire Area School District
Eau Claire County
Please Indicate Availability (Please select the options below that will work in your schedule. Groups will be created after reviewing forms submitted by participants, and you will receive an email confirming specific meeting times and dates. Each group will meet at a specific time and day each week for 6 weeks. Groups will not meet more than once per day, but please mark all the times that could work for you.)
Mondays 3:30-5:30 pm
Mondays 4-6 pm
Fridays 9-11 am
Saturdays 10 am-noon
Do you require disability accommodations? If so, we will follow up individually.
How did you hear about Circles of Change?
Page 1 of 1
Never submit passwords through Google Forms.
This content is neither created nor endorsed by Google.
Terms of Service