The first part of this form includes questions about you as an individual. The second part asks about the organization you are affiliated with. Not all questions are required, however, all information will be used to forward Digital Equity in Lake County. Please fill out the form as you're most comfortable. If a question doesn't apply, please type N/A.

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* 1. First Name

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* 2. Last Name

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* 3. What are your pronouns? (Optional)

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* 4. Title

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* 5. Preferred email for Coalition communications?

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* 6. Preferred phone number for Coalition communications?

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* 7. Which race(s) or ethnicity(s) best describe you? (Optional)
We strive to achieve a diverse and representative Coalition. Please check all that apply.

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* 8. What are good times for you to attend meetings on weekdays?
Please check all times that apply. We will do our very best to accommodate times that work for most.

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* 9. If we were to host in-person meetings, which location would you prefer?
If you're interested in hosting a coalition meeting at your organization’s space, please indicate the name and location of the site under “other.”

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* 10. Please describe any additional schedule restrictions or things we should know pertaining to when you can meet.

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* 11. Would you prefer to engage in meetings through a Spanish-speaking interpreter?

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* 12. Do you have any food allergies/dietary restrictions?
If so, please list here or type N/A.

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* 13. What else do you need to ensure you are able to engage in meetings (virtually or in-person)?
Please use this space to further elaborate on any of your above responses or other accommodations you may need.

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* 14. If you were to participate in a committee on the Digital Equity Coalition, which topics would you be interested in?
Please select all that apply and note that all topics should be tied into Digital Equity in some respect.

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* 15. Organization Name

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* 16. What are your organization’s social media handles?

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* 17. What type of organization are you affiliated with?

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* 18. Which community or area of the county does your organization serve, or if you’re a Resident, where do you live?
Please select all that apply

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* 19. Does your organization serve unincorporated communities?

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* 20. What population does your organization serve?
Please select all that apply

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* 21. Which types of services does your organization provide to the populations you serve?

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* 22. What has your organization already done to bridge the Digital Divide?

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* 23. In 1-2 sentences, please share why you are interested in joining the Digital Equity Coalition.

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* 24. Have you read Lake County’s Broadband and Digital Equity Plan?

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