JavaScript isn't enabled in your browser, so this file can't be opened. Enable and reload.
Registration for YOUR VOTE DOES MATTER
Presented by VA BLOC and hosted by Ivy Baptist Church
Monday, September 26th 7:00p-8:30p
Ivy Baptist Church - 50 Maple Ave, Newport News, VA 23607
Please fill out this form to register.
Sign in to Google
to save your progress.
Learn more
* Indicates required question
First Name
*
Your answer
Last Name
*
Your answer
Street Address
Your answer
City
*
Your answer
State
Your answer
Zip Code
*
Your answer
Are you interested in learning more about VA-BLOC and how YOU can get involved?
*
Yes
No
Maybe
How did you hear about this event?
*
Internet/Website
Social Media
VA-BLOC Team Member
Other:
Required
What are your top three (3) concerns in your community?
*
Education
Criminal Justice Reform/Dismantling the Pipeline
Economic Security
Mental Health
Community Policing/Violence Prevention
Environmental Justice
Other:
Required
Are you registered to vote?
*
Yes
No
No, I need my rights restored.
Other:
Are you a college student?
*
Yes
No
Submit
Clear form
Never submit passwords through Google Forms.
This form was created inside of New Virginia Majority.
Report Abuse
Forms
