The Citizens who Care
Information Form

The purpose of this form is to give us an idea of your experience, availability and interest. This information will be kept confidential unless you specifically sign that the information is available to the public. The reason for this is to protect you from reprisal by people or organizations that are targeted by your work and that pressure not to be applied by your current clients or social, civic or governmental organizations. Print this, fill it out and snail mail it to us.

Name: First ___________________Middle___________ Last_____________________Date_______

Mailing Address __________________________City________________State___Zip Code _______

Contact Information: Phone _______________Cell_________________E-mail__________________

Other ____________________________________________________________________________

Areas of Skill: Marketing __; Public Relations __; Sales Promotion__; Creative Development__: Copy Writer__;
Graphic Artist__; Photographer__; Web Designer__; Media__; Research__; Other__________________________________________________________________________

Areas of Interest: Marketing __; Public Relations __; Sales Promotion__; Creative Development__: Copy Writer__; Graphic Artist__; Photographer__; Web Designer__; Media__; Research__; Other__________

Primary Firms You've Worked for in your Career_________________________________________

Employment status: Working for a Company__; Work as Freelance__; Unemployed__; Retired__; Other___________________

Categories of Interest: Abuse__; Addiction__; Adolescence__; Aging__; Alcohol__; Alcopops__; Andropause__: Body Piercing__; Breast (cancer, feeding, implants,)__; Bulling/hazing__; Cancer (breast, cervical, prostate, testicular, other)__; Child Abuse__; Children__; Custody__; Support__; Contraception__; Cosmetics__; Crime__; Depression__; Diabetes__; Disabilities__; Diversity__; Divorce__; Drinking/Binging__; Domestic Violence__; Drugs: Illicit__; Prescription__; Eating Disorders__; Energy Drinks__; Environment__; Euthanasia__; Families__; Father Involvement__; Gambling__; Gangs__; Gay/Lesbian __; General Health__; Harassment__; Helmet laws__; Homophobia__; Immunization__; Impotency__; Inhalants__; Internet Safety__; Juvenile justice__; LGBTQI Issues___; Longevity__; Medical Marijuana__; Men__; Menopause__; Mental Health__; Mentoring__; Multicultural__; Nutrition__; Obesity__; Parenting__; Poison Control__; Prison__; Racism__; Recovery__; Reproduction__; Ritalin__; Safer Sex__; Self-injury(EMO)__; Seniors__; Sex Ed__; Shaken Baby Syndrome__; Single parents__; Smoking/Dip__; STIs__; Suicide__; Tattoos__; Teens__; Teen Fathers__; Teen Pregnancy__; Veterans__; Violence__; Visitation__; Women__. Other_________________________________________________________

Sign here if you grant permission to connect your name to projects you work on for CWC________Date___

Send completed form to CWC, PO Box 12, Brookings, OR 97415