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
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