Name *

First Name

Last Name

Phone

In case something goes awry during our call. Technology isn't always on our side.

(###)

###

####

Address

Only to thank you

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Did you post a black box on June 2, 2020?

Yes

No

Did you post a statement of solidarity at your workplace any time after April 2020?

Yes

No

What best describes you:

White

BIPOC

AAPI

If you selected white, do you consider yourself an ally?

Yes

No

Are your efforts towards anti-racism

Personal

Work related

Both

I have conducted difficult conversations about areas of diversity, equity and inclusion with:

Friends

Family

Co-workers

No one, yet