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 Year19201921192219231924192519261927192819291930193119321933193419351936193719381939194019411942194319441945194619471948194919501951195219531954195519561957195819591960196119621963196419651966196719681969197019711972197319741975197619771978197919801981198219831984198519861987198819891990199119921993199419951996199719981999200020012002200320042005200620072008200920102011201220132014201520162017201820192020 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 Education Justice Enforcement Resistance Federal Immigration Policy Healthcare Workplace Justice Community Navigator Trainings Submit
