National Diversity & Inclusion Cannabis Alliance (NDICA) - Intake Form 

[ESPAÑOL ABAJO] 

Please fill out this form if you are attending the event on: 04/28 AT LITTLE VILLAGE HIGH SCHOOL

Please fill out this form even if you've filled out this form at a previous event. We are required to collect information from all event participants regardless if they've attended a previous event! Thank you!

Complete este formulario si asistirá al evento el: 04/28 AT LITTLE VILLAGE HIGH SCHOOL

Complete este formulario incluso si lo ha completado en un evento anterior. ¡Estamos obligados a recopilar información de todos los participantes del evento, independientemente de si han asistido a un evento anterior! ¡Gracias!

Sign in to Google to save your progress. Learn more
SCAN THIS QR CODE TO ACCESS FORM ON ANOTHER DEVICE
E-mail Address *
First Name *
Last Name *
Phone Number *
Mailing Address (Including City, State, & Zip Code) OPTIONAL
Age Range *
Gender *
Ethnicity *
Race *
Have you ever witnessed gun violence OR been victim of a gun violence?
 *
Are you related to someone that is a victim of gun violence?
 *
Are You Currently Employed? *
Are You Seeking Employment? *
Please select all of the services that you are receiving from NDICA today  *
Required
Have you received Medicaid, Supplemental Security Income, Social Security Disability, and/or subsidized housing for at least 5 of the past 10 years?  *
PRIMARY LANGUAGE SPOKEN *
Required
Any other information you'd like to share or any additional services you are seeking?
Submit
Clear form
Never submit passwords through Google Forms.
This form was created inside of University of Michigan. Report Abuse
Google Forms