Submitted by maria on Fri, 10/12/2018 - 14:17 Your Contact Information First Name * Last Name * Organization Name Birth Date * MonthJanFebMarAprMayJunJulAugSepOctNovDec Month Day12345678910111213141516171819202122232425262728293031 Day Year19211922192319241925192619271928192919301931193219331934193519361937193819391940194119421943194419451946194719481949195019511952195319541955195619571958195919601961196219631964196519661967196819691970197119721973197419751976197719781979198019811982198319841985198619871988198919901991199219931994199519961997199819992000200120022003200420052006200720082009201020112012201320142015201620172018201920202021 Year Street Address City State Zip Code Phone Number * Email * Monthly Youth Calls (Please check the calls you want to attend): * PICC Youth Monthly Call February, 2020 - February 12th, 2020 7:30 PM PICC Youth Monthly Call March, 2020 - March 11th, 2020 7:30 PM PICC Youth Monthly Call April, 2019 - April 8th, 2020 7:30 PM PICC Youth Monthly Call May, 2019 - May 13th, 2020 7:30 PM PICC Youth Monthly Call June, 2020 - June 10th, 2020 7:30 PM Preferred Communication Method(s): Phone Email Postal Mail SMS Preferred Language for Communications (Please select one): - None -ArabicChineseEnglishSpanish Anything thing else you'd like to let us know about your preferred language for communication (Please describe)? Issues Interest(s): Access to Drivers Licenses Campaign to Shut Down Berks Community Navigator Trainings Education Justice Enforcement Resistance Federal Immigration Policy Healthcare Tuition Equity Campaign Workplace Justice Submit
