Informal Outreach Submission Form

Demographic information is used for assessing our outreach efforts and is essential for future funding of our program. Your name and contact information will never be submitted to our financial supporters. Only demographic information will be used. Contact information is used solely to contact you with your permission to keep you up-to-date with FUSION events and activities.

Please provide the following contact information:

Full Name
Street Address
Address (cont.)
City
State/Province
Zip/Postal Code
Country
Work Phone
Home Phone
E-mail

Do you want to be included in our list-serve?

Yes No

Do we need to be discrete when you contact you?

Yes No

Choose one of the following options:


Choose one of the following options:


Choose one of the following options:


Select any of the following options that apply:

White
Native American
African American
Hispanic/Latino
Asian
Hawaiian/Pacific Islander
Middle Eastern
Other

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