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Civic Academy Application
Civic Academy Application
First name
Last name
Preferred pronouns
City
County
Address
Email
Phone number
Organization or company
Zip code
Age
- Select -
18-34
35-44
45-54
55+
Ethnicity (check all that apply)
American Indian or Alaska Native
Black or African American
Hispanic, Latino, Spanish
Native Hawaiian or Other Pacific Islander
Asian
Middle Eastern or North African
White
Two or more races
Preferred name or nickname
Gender
- Select -
Male
Female
Non-binary
Prefer not to say
Prefer to self-describe
Are there other accommodations or considerations we should know? Diet, childcare, wheelchair accessibility, translator, etc
Industry
Architecture
Arts and Culture
Business/Finance
Construction
Consulting
Education
Health Care
Information Technology
Legal
Manufacturing
Government
Real Estate/Development
Student
Prefer not to answer
Other (please specify)
Other industry
Business address
Business city
Business zip code
Please list personal/professional organizations or affiliations.
Elected or appointed positions (past or present)
Yes
No
Please list elected or appointed positions (past or present)
How did you hear about the Civic Academy? (choose all that apply)
DRCOG website
DRCOG email
Civic Academy graduate
Friend/colleague
Employer
Community-based organization
Social media (Facebook/Twitter)
Local government
Flyer
Other
How did you hear about the Civic Academy?
Participants in the Civic Academy are required to develop an Individual Action Plan. Each action plan will describe future efforts to address local or regional issues with the potential to transform our collective future. Individual Action Plans will be developed throughout the course of the seven-week program (more info is available on the FAQ page). If selected, which category below best reflects the topic you think you might craft your Action Plan around? *
Bicycling/Walking/Pedestrian Access
Community Outreach/Education
Community Planning/Development
Transit Corridor/TOD/Station Design
Housing
Economic Development
Health/Environment
Equity/Access to Opportunity
Community planning and technology
Other (please specify)
Other category
Can you devote three hours per week for seven weeks?
Yes
No
Email to use in the participant directory
Social media handles to list in the participant directory
I have read and agree with the disclaimer.
Yes
No
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