This is a form for submitting contact information for your membership at CBCAC. If you have any questions, contact us at

Privacy Notice

Coalition for a Better Chinese American Community (CBCAC) collects personal information, such as your name, email, address, phone number, etc., when you register to be a member. CBCAC collects personal information via Google Form, and the information subsequently stores on Google Sheets. The personal information collection process is subjected to the Privacy Policy of Google, Inc. The information will only be used for contact purposes within the organization. CBCAC respects your personal privacy. To the extent permitted by law, we will not release your name, address, phone number, or email address to a third party without your consent. If you are no longer a member of CBCAC, you could submit a request to delete the storage of your personal information via

Email address *
Name *
Please type your first and last name
Your answer
Phone number *
Your answer
Your answer
Date of Birth *
Which of the following best describes you?
What is your proposed role in ORIGIN? *
College students or those in the workforce will participate in ORIGIN as advisors. Those in high school or lower are members.
Do you consent to having your headshot and contact information (i.e. email) on the ORIGIN Youth Group website? *
Membership Agreement
By signing this section, you agree to be a member/advisor of the CBCAC ORIGIN Youth Group and follow the requirements and expectations of CBCAC ORIGIN Youth Group, which are explained in ORIGIN Youth Group Member Handbook and ORIGIN Advisory Committee Handbook, whichever applies to you. Being a member/advisor of ORIGIN, you shall respect and care for your fellow members/advisors. CBCAC will not be responsible for any activities or gatherings outside of the ORIGIN Youth Group formal meeting sessions.
Signature *
Please put in your name for now. When you attend a meeting, we will prepare a physical copy of your responses for you to sign.
Your answer
Date *
Your answer
Parent/Guardian's Name (if under 18 years old)
Your answer
Parent/Guardian's Phone Number (if under 18 years old)
Your answer
Parent/Guardian Signature (if under 18 years old)
Again, please type in their name for now. Have your parent or guardian sign the copy given to you after attending one meeting.
Your answer
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