Billing Contact Name:
Billing Contact Phone:
Billing Email Address:
Point Person for your Team or Group
Point Person Email:
Point Person Phone:
Short Answer Questions
What city do you live in?
What is your current role in your organization:
How long have you been in your current role in your organization?
Please explain the current campaign you are working on?
How have you been impacted by the Black jobs crisis and/or mass incarceration?:
What impact has the COVID-19 pandemic had on you, your family and your work life? What changes have you had to make to adapt?
What other issues are you involved with or care about? What organizations or groups are you a part of?
What do you hope to gain from your participation in the C.L. Dellums African American Leadership School?
If you are not currently in a leadership role, do you aspire to be in a leadership role in the future?
Please elaborate on your leadership development plans. What kind of experience and skills building would you want to build on or obtain?
What are some opportunities and resources available to you in your organization?
What are some of the obstacles or lack of resources in your organization? How do you plan to move forward given the challenges?
What is your vision for strengthening your organization and or building power for your membership base?
Race:Asian/Asian AmericanBlack/African AmericanCaucasian/WhiteNative AmericanLatina/o/ePacific IslanderOther
Are you an Immigrant:–None–YesNo
What country are you from:
Preferred Gender Pronouns: