First Name: Last Name: Telephone:
Address: Community: Postal Code:
Email Address:
Interests:
Please list any knowledge, skills and experience (professional and/or personal) that may be beneficial for serving on a Town of Stratford committee:
Committee Choices Is there a particular committee(s) you are interested in joining? Yes No If yes, please specify: Choice #1 Choice #2 If you have identified specific committee choice(s) above, would you consider another committee outside of these selections (otherwise leave both selections blank)? Yes No
Your voluntary response to the following diversity questions will assist us in determining whether the Town of Stratford committees are representative of the diverse residents we serve. The information is confidential and only used for statistical and diversity representation purposes.
Are you: Male Female Transgender, non-binary, two-spirit Prefer not to answer
Age Range: 12-18 years 19-30 years 31-50 years 51-65 years +65 years
Do you identify as a person with a disability? Yes No
What is your first language? English French Other (please specify):
Are you proficient in other language(s)? Yes No If yes, please specify all:
Do you identify yourself as a minority or under-represented group? Yes No
Other Questions:
Over the next two years, there are may be other opportunities to volunteer with the Town of Stratford on a one-time or short term basis. These may include things like special events, focus groups, or topic specific work. Would you be interested in being contacted to participate in other volunteer opportunities if/as they arise? Yes No