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2. Hello! Thank you for your interest in joining our community focus group. Please complete this form to register for our CHIP facilitation and discussion. Your participation will help us improve our community's well-being for all residents and visitors. We value your time and welcome any feedback you can provide. Thank you for your support!

4. 1. Which facilitation are you planning to attend?*

   1. Mattawa
   2. Moses Lake
   3. Royal City
   4. Ephrata
   5. Grand Coulee
   6. Quincy
   7. Warden
   8. Other
6. If Other, please enter your answer:
8. 2. Please provide your preferred email address for CHIP communication.*
10. 3. In which zip code do you live?
12. 4. Which best describes your gender? (Select all that apply.)

    1. Woman
    2. Man
    3. Non-binary
    4. Trans
    5. Prefer not to say
    6. Other
14. If Other, please enter your answer:
16. 5. Which best describes your race?

    1. White
    2. Black or African American
    3. American Indian/Alaskan Native
    4. Native Hawaiian/other Pacific Islander
    5. Asian
    6. Other
18. If Other, please enter your answer:
20. 6. What best describes your ethnicity?

    1. Hispanic or Latino/a/x
    2. Not Hispanic
22. 7. What is your current occupation or role?
24. 8. What is your age?
26. 9. Do you have any dietary needs/preferences?*

    1. No dietary needs/preferences
    2. Vegetarian
    3. Vegan
    4. Gluten free
    5. Dairy free
    6. Peanut allergy
    7. Other
28. If Other, please enter your answer:
30. 10. What is your preferred language for this facilitation and future contact regarding the CHIP?

    1. English
    2. Spanish
    3. Other
32. If Other, please enter your answer:
34. 11. Do you have any specific accessibility needs for this facilitation meeting? Please indicate below. We will do our best to accommodate them.
36. 12. How did you hear about these community listening sessions?*

    1. Social media
    2. Flyer
    3. Email invitation
    4. Chamber newsletter
    5. Newspaper
    6. Radio
    7. Friend
    8. Other
38. If Other, please enter your answer:
Leave This Blank:


42. 1. Receive an email copy of this form.
43. Email address

    This field is not part of the form submission.

44. Submit

* indicates a required field