Please fill out the entire form, both columns, and then click "done" at bottom. Your information will be visible only to the designated users from the organizations you choose, or may be made available to the designated users at all four organizations if you so desire.

  • * First Name:
  • * Last Name:
  • * Organization/Institution:
  • * Street Address:
  • * City:
  • * State:
  • * ZIP code:
  • * Phone number:
  • * Email:
  • Preferred contact method:

  • Don't recognize the organization abbreviations? More information on each is available on their web sites:
    Alternatives for Community and Environment
    Boston University School of Public Health
    Toxics Action Center

    Do you want access to your name and contact information restricted to the organization that referred you to the database? (If you did not select an organization above, or if do not choose to restrict your information by checking the box below, your name and contact information will be visible to all the listed organizations. Your name and contact information will never be visible to the public.)

     

  • Degree(s) or professional license(s):
  • Year of primary degree or license:
  • Affiliations:

    For example, organizations with which you work on a professional or volunteer basis.

  • Level of engagement

    • Come to a community meeting to translate or present scientific information
    • Develop a long-term collaborative program
    • Fact-check document (e.g., fact sheets and reports)
    • Give expert testimony
    • Provide legal advice via phone or meeting
    • Provide legal representation
    • Respond to brief questions or quick advice via phone or e-mail
    • Review a plan / a risk assessment / an EIS / etc
    • Sign letters / editorials
  • If students are available for project work, please detail course, experience level, and time available:
  • Non-English language proficiency:

    • American Sign Language
    • Cape Verdean Creole
    • French
    • German
    • German
    • Greek
    • Haitian Creole
    • Hindi
    • Hindi, Gujarati
    • Italian
    • Italian
    • Japanese
    • Khmer
    • Malayalam
    • Mandarin
    • Persian
    • Portuguese
    • Punjabi - baic
    • Russian
    • Serbian
    • Spanish
    • Spanish & Punjabi - basic
    • Swahili
    • Thai
    • Vietnamese
    • Other:
  • Experience working with:

    • Communities of color
    • Community organizations
    • Disabled
    • Immigrant
    • Low-income
    • Native American / tribal governments
    • Workers
  • Summary of interests. Please include any keywords that people might use in searches.