New England Grassroots Environment Fund · REGISTRATION: New Hampshire Grassroots Sustainability Gathering: Catalyzing Collaboration through Stories, Tools, & Funding

Contact Information

Name

*

First Name

Last Name

Email

*

Phone

Organization/Employer/Affiliation/School (if no affiliation, you can also write "community member")

*

What pronoun do you prefer to use? (i.e. she, he, they, etc.)

*

Are you comfortable with us sharing your contact information (name, affiliation, county, & email) with other attendees of the event?

*

Yes

No

Email preferences

Which of our email lists would you like to be subscribed to?

Quarterly news and trends from across the region (4/year)

Upcoming grant program deadlines (3/year)

Notifications about Grassroots Fund trainings and events (1-2/month)

Stories/videos about innovative community projects across the region (2/month)

Your Perspective

Other:

How would you classify the main group/organization with which you affiliate?

Ad hoc grassroots/community group

Non profit organization

Foundation/funder

Private business/consulting University

Municipal/state organization

Other

What are you most passionate about? (in 4 words or less!)

This will be included on your name badge to facilitate networking at the event.

Is there anything else you would like to share about the perspective you bring?

Other:

Grant Funding Available!

Funding for groups is available through the New England Grassroots Environment Fund's Seed (up to $1,000), Grow (up to $3,500), and Young Adult Leaders (up to $7,500) Programs. You can find out more information about these programs and minimum eligibility guidelines here: https://grassrootsfund.org/dollars.

Are you interested in applying for funding for a community project?

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Yes

No

Maybe, I'm not sure

Are you interested in reviewing grant applications (you can both apply to the Fund and serve as a reviewer as we will avoid conflicts by not assigning you to review your own application).

*

Yes, I will sign up to participate!: https://grassrootsfund.org/participate

No, thank you.

Maybe, I will decide after the event.

Museum Tour & Reception

The Catalyst Conversation Event will run from 4 p.m. - 7 p.m., with registration beginning at 3:30 p.m. The Museum will be offering a FREE tour for all Catalyst Conversation participants before the event from 2:30 -3:30 p.m. We will also be hosting a Friends & Donors Reception with local food appetizers and beverages from 7:00 p.m. - 8:00 p.m.

I will be joining for:

*

Tour of Mt. Kearsarge Indian Museum (2:30 - 3:30 p.m.)

Catalyst Conversation Program (4:00 p.m. - 7:00 p.m.; registration @ 3:30 p.m.)

Reception (7:00 - 8:00 p.m.)

Dietary Restrictions

We will be providing a meal at the event and strive to source as much local and organic food as possible. Please let us know if you have any dietary restrictions/preferences.

Gluten Free

Vegan

Vegetarian

Sugar Free

Dairy Free

Other:

Participation Support

We strive to lower barriers to attendance at the event. Please let us know if there is anything that will help you participate. We will do our best to provide support and reimbursement on an as-needed basis and as funding allows. A Grassroots Fund staff member will follow up to confirm if funding is available or discuss your request.

Are you interested in carpooling to the event?

Yes, I will find my carpool buddy here: https://www.groupcarpool.com/t/n6ocgr

No, thank you

Will you need any financial support to allow you to participate in the event?

*

Yes

No

If yes, what kind of support do you need?

(limited reimbursements / stipends available)

Travel reimbursement

Childcare reimbursement

Stipend for missed work

Other (please list below)

Other:

What is the total amount you expect to need? Please breakdown the expenses if multiple types of support are requested.

Would language translation be helpful for your participation?

Yes

No

If yes, what language?

Is there anything else that would help you participate?

Demographic Questions

We strive to ensure that we have a diversity of perspectives across race, class, gender, and other identifiers represented in all our program and events. This survey helps us better understand how you self-identify across a number of demographic characteristics. We will only share information from this survey as an overall summary and we will not disclose any information about specific people.

Please select your age bracket:

Under 25

26 - 35

36 - 45

46 - 55

56 - 65

66 -75

76+

Wish to not disclose

You self identify as:

Female

Gender queer, intersex, or non-binary

Male

Transgender or transexual

Wish to not disclose

You self identify as:

LGBQQ (Lesbian, Gay, Bisexual, Queer, Questioning)

Asexual

Heterosexual

Wish to not disclose

Please share which perspectives you most closely identify with:

Rural

Suburban

Urban

Wish not to disclose

Please share the socioeconomic class that you self-identify with:

(Household income brackets are taken from William Joseph & Joseph Hickley academic class model. They merely serve as one possible measure for socio-economic status. If you do not feel that the household income brackets accurately reflect the socioeconomic class you represent, please choose the class option that you feel is most reflective)

Lower class (annual household income under $16,000)

Working class (annual household income between $16,000 and $35,000)

Lower middle class (annual household income between $35,000 - $75,000)

Middle middle class (annual household income between $75,000 - $100,000)

Upper middle class (annual household income over $100,000)

Upper class (annual household income over $500,000)

Wish not to disclose

In terms of race and/or ethnicity, how would you describe yourself?

(If you prefer to select from commonly used census categories, please select from the options below. If you would prefer to use an open answer text box to describe please select the 'prefer to use text field')

Asian

Black or African American

Indigenous American or Alaskan Native

Latinx/ Hispanic /of Spanish origin

Middle-Eastern or North African

Native Hawaiian or Other Pacific Islander

White

Prefer to use text field (use next question)

Wish not to disclose

Please use this space if you would prefer to use an open answer text box to describe in your own terms how you identify.