Name *

First Name

Last Name

Phone

(###)

###

####

Availability

Weekdays (Day Time)

Weekdays (Evening)

Weekends (Day Time)

Weekends (Evening)

Are you comfortable speaking to residents at their doors about the program?

This may require walking through neighborhoods with steep grades

Yes

No

Are you comfortable speaking public events?

Yes

No

Do you need accommodations to do any of the activities listed?

Talking to residents, walking up/down hill or mobility restrictions, attending public events

Yes

No

Do you have a smartphone you are willing to use for this program

Yes

No