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Grassroots Leadership Registration
Applicant Name:
Email:
Address:
City:
State:
Zip:
Phone Number:
Alt Phone:
Name of Organization and title (if applicable):
Gender:
Male |
Female
County of Residence:
Hillsborough |
Pinellas |
other
Age Range:
15-19 |
20-29 |
30-39 |
40-49 |
50-59 |
60+
Race:
African American |
Asian |
Caucasian |
Hispanic |
Other
Primary Area(s) of Interest:
Affordable Housing
Senior Issues
Faith-based
PTA/Schools
Health and Nutrition
Community Cleanup
Economic/Business Development
Neighborhood Associations
Youth/Civic Engagement
Crime/Community Safety
Parks/Beautification
Other (please list separated by commas):
What issues do you want addressed/changed in your community?
COMMITMENT CLAUSE: I understand that this program has limited
seating and my selection is based on my level of commitment
to the program. The curriculum consists of four Saturday sessions
and I agree to complete at least three of the four sessions
to receive the program Certificate of Completion, and to be
eligible for other benefits associated with this program.
Marketing and Communications Assistant
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Kingian Intinerary
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Kingian Nonviolence Registration
Jim Walter Partnership Center ♦ University of South Florida ♦ 4202 E. Fletcher Ave MGY132 ♦ Tampa, FL 33620 ♦ (813) 974-5709
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