North Central Massachusetts Minority Coalition

Minority Coalition Membership Form

Any individual can become a member of the Coalition by providing membership data and agreeing to support minority leadership, and the growth and development of the Coalition. Individual members will not pay dues.
 
Salutation:
First Name:  
Last Name:  
Phone:
Email:
Street Address:
City:
State:
Zip:
Gender:
Are you a registered voter?
Have you ever participated in voter registration?
What is your age range?





What is the highest level of education you have completed?




What is your current employment status?





Would you be willing to volunteer to support the Coalition's work?
Are you head of household?
How many people live in your household?
What are your most valuable skills?
Are you a business owner?
Do you have health coverage?
Are you a homeowner?
Are you of Hispanic, Latino, or Spanish origin?



If you checked "Yes, another Hispanic, Latino, or Spanish origin", please specify (for example, Argentinean, Colombian, Dominican, Nicaraguan, Salvadoran, Spaniard, etc)
Check all that apply:
















If you checked "Other Asian, Other Pacific Islander, or Other Not Listed", please specify: