First name
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Last name
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Mobile phone
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Email address
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City
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State
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State
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
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Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
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Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
Washington, D.C.
West Virginia
Wisconsin
Wyoming
Region
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ZIP Code
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Postal code
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Could you describe your location?
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Rural Suburban Urban Other
If you answered “Other” in the above question, please describe the type of location.
Age Range
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Under 18 18–24 25–34 35–44 45–54 55–64 65+
Race and Ethnicity (Checkboxes — select all that apply)
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American Indian or Alaska Native Asian Black or African American Hispanic or Latino Middle Eastern or North African Native Hawaiian or Other Pacific Islander White Other
If you answered “Other” in the above question, please tell us the race and/or ethnicity.
What languages do you speak?
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Arabic Cantonese English French German Haitian Creole Korean Mandarin Portuguese Russian Spanish Tagalog Vietnamese Other
If you answered “Other” in the above question, please tell us the other language you speak.
Select the issues most important to you. (Checkboxes — select all that apply)
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Agriculture Climate, Energy, and the Environment Criminal Justice Reform Democracy (i.e., the Constitution, Voting Rights, Civil Rights, etc.) Disability Rights Economy (i.e., Jobs, Inflation, Tariffs, Trade, Cost of Living, Wages, Labor, etc.) Education Faith Foreign Affairs Gun Violence Prevention Health Care (i.e. Increased Premium Costs, Rural Hospital Closures, Access to Care) Housing Immigration Reform Infrastructure (i.e., Broadband, Transportation, Utilities, Roads, Bridges etc.) LGBTQ+ Rights Medicare/Medicaid National Security Racial Justice Reproductive Rights Small Businesses Social Security Veterans and Military Families Other
If you answered “Other” in the above question, please tell us the other issues most important to you.
Tell us which formats you’re comfortable with. (Checkboxes — select all that apply)
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Audio Community Event Interview Press Conference Recorded Video Social Media Written Testimonial Other
If you answered “Other” in the above question, please tell us the other formats you're comfortable with.
We sometimes feature voices in news media and publications. Please select the opportunities you’re open to. (Checkboxes — select all that apply)
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Op-ed or Guest column Quoted in News Articles Radio Interview TV Interview Background Interview with Reporters Photo Feature Other
If you answered “Other” in the above question, please tell us the other opportunities you're open to.
Please share a short version of your story: Briefly tell us about your story and why a specific issue/topic is important to you. Is there a specific event, policy, or personal experience that illustrates your story? Feel welcome to include professional affiliations, occupation, and more.
Please let us know if you require any accessible accommodations to participate in this program.
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Did someone recommend you? If so, please provide their name and or affiliation.
We take your privacy seriously. Your story will not be shared publicly without your permission.
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I give permission for my story and likeness to be shared for advocacy and media purposes. I prefer my story to be used anonymously. I do not give permission for public sharing, unless otherwise approved by me.