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2. Name
3. Phone Number
4. Email Address
6. Why are you interested in serving our community?*
8. Please describe your relationship with Winooski? (Resident, business owner, student, etc?)*
10. Tell us about how you would work towards changing the impact of the environments where social interaction takes place, on the lives of people from culturally diverse groups?*
12. What do you know about power, privilege, and how they affect the experience of different culture groups?
14. Additional Commission Service

    Participation on the Inclusion and Belonging Commission requires placement as an ambassador on an additional city commission. Please identify your interest in serving on the following city commissions in order of preference - 1 being first choice, 5 being last choice.

16. Planning Commission

    (planning, zoning, ordinences) 

17. Safe, Healthy, Connected People Commission

    (parks, pool, senior center, library, programs, etc.) 

18. Housing

    (home ownership, renting, affordability, etc.) 

20. Municipal Infrastructure Commission

    (streets, sidewalks, water systems, etc.) 

21. Finance Commission

    (city budgets, spending, grants, etc)

23. Interpretation Requests

    Language interpretation and childcare services can be requested by any commissioner on an as-needed basis.

25. Will you need interpretation services?

    1. Yes
    2. No
27. Waiver*

    I recognize that as human beings, we all intersect in multiple identities drawn from race, gender identity, sexual orientation, religion, ability & ethnicity. I know that differences in race, culture & ethnicity are essential and valued parts of an inclusive society, and recognize that these different perspectives are an asset to the City of Winooski. I understand and agree that submitting this application form does not qualify as automatic registration and that certain qualifications must be met (including the acceptance of established policies and procedures provided by the organization of interest). By clicking yes and submitting this form, I attest that the information I have provided on the form is true and accurate. 

    1. Yes
29. Full Name*
30. Today's Date*
    Today's Date
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32. 1. Receive an email copy of this form.
33. Email address

    This field is not part of the form submission.

34. Submit

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