2. First Name*
3. Middle Name
4. Last Name*
6. Preferred Pronoun:
8. Address*
10. City
11. State
12. Zip Code
14. Phone Number*
15. Email Address*
17. Current Grade/Year of Enrollment
19. Area(s) of Interest

    (please check all that apply):

    1. Human Trafficking
    2. Intersection between Domestic Violence & Human Trafficking
    3. All Areas of Discrimination
    4. Discrimination in Employment
    5. Discrimination in Education
    6. Discrimination in Law Enforcement

    1. Discrimination in Public Accommodations
    2. Discrimination in Residential Real Estate (Housing)
    3. Discrimination in Commercial Real Estate
    4. Social Justice/Civil Rights
    5. Language Access
21. How many hours in a week can you commit to the virtual Youth Leadership Academy?
23. Please provide a maximum one-page response (be creative!) to one of the following questions:

    1. In a perfect world, what does social justice look like?
    2. If you were given $1 million, what would you do with it?
    3. Describe your perfect job/career and why.
25. In a perfect world, what does social justice look like?
27. If you were given $1 million, what would you do with it?
29. Describe your perfect job/career and why.
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31. 1. Receive an email copy of this form.
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