Fulton Citizens University Form

Title Please Select One Miss. Ms. Mrs. Mr. Dr. Street Address City State Zip Code Home/Cell Telephone Number Email Gender Male Female Eligibility: Participants must be residents of Fulton County, work or have a business in Fulton County, or be an enrolled student in a Fulton County college or university. CIVIC INVOLVEMENT:Do you currently serve on a county board or commission? yes no If yes, please which board/commission: Please list any community involvement in the past 5 years. Please list any leadership positions you've (currently/previously) held in Fulton County PROGRAM INTEREST/GOALS:What are your participation goal(s) for Citizens University? What services or government functions are you primarily interested in learning more about? How did you hear about the Fulton County Citizens' University Program? Attendance:Can you attend all Citizen University classes? Yes No If no, which dates are you NOT able to attend: Do you require any special accommodations to participate, including reasonable accommodations for a disability, special dietary needs, or others? Please specify. Yes No If yes, please explain: EMERGENCY CONTACT INFORMATION In case of emergency, who should we contact? Emergency Contact Last Name Emergency Contact First Name Emergency Contact Street Address Emergency Contact City Emergency Contact State Emergency Contact Zip code Emergency Contact Phone Number Emergency Contact Email Address Fulton County is an equal opportunity employer encouraging diversity and inclusion. If you need reasonable accommodations or modifications due to a difference in ability, including communications in an alternate format, please contact 404-612-7390. For TDD/TTY or Georgia Relay Service Access, dial 711.