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 Year19221923192419251926192719281929193019311932193319341935193619371938193919401941194219431944194519461947194819491950195119521953195419551956195719581959196019611962196319641965196619671968196919701971197219731974197519761977197819791980198119821983198419851986198719881989199019911992199319941995199619971998199920002001200220032004200520062007200820092010201120122013201420152016201720182019202020212022 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
