Organization Name

Date Established

First Name

Last Name

First and last name will be shared with other visitors to the site.

Street (Home)

City (Home)

Postal Code (Home)

State (Home)

Country (Home)

Your state and country of residence will be shared with others so folks can find others in their community.

Primary Phone

Cell / Mobile Phone (with text capabilities)

Are you affiliated with the organization

Please state your organizational mission. (255 character MAX)

How do you feel your work aligns with the Alternate ROOTS mission as you understand it? (255 character MAX)

We collect demographic information for grant purposes. How do you identify? (Check all that apply)

Person of ColorPerson with a DisabilityLesbianGayBisexualQueerTransGender non-conformingMilitaryYouthFormerly IncarceratedNot Applicable/No Answer

How do you identify ethnically? (Please check all that applied)

American Indian or Alaska NativeArab, Arab American, Middle EasternAsianBlack or African AmericanHispanic or LatinoNative Hawaiian or Pacific IslanderOtherWhiteIndigenous, Native American, First PeoplesMENASAAPI (Middle Eastern, North African, South Asian, Pacific Islander)

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Income Level

Under $9,999$10,000 - $20,000$20,000 - $35,000$35,000 - $50,000$50,000 - $80,000$80,000 - $100,000$100,000+

Highest level of education

Did not complete high schoolHigh School graduateSome collegeAssociate's degreeBachelor's degreeMaster's degreeDoctoral or Professional degree

Would you like to make a donation?

YesNo

Amount

Would you like to donate a membership?

YesNoEach Membership is equivalent to $40

Number of memberships to donate.

Who should receive the donated membership(s)

Member Fee

MemberDonationTotal

Total Amount Due

* NOTE:
Once you complete your payment you will be directed to ROOTS Member Directory Form. Please complete your member profile including high resolution image. Always keep your profile up to date. Welcome to ROOTS!

How would you like to pay for your membership?

Credit CardCheck

Please mail your check (payable to "Alternate ROOTS") to our office at: 1270 Caroline St Box D120-353 Atlanta, GA 30307

Payment Information

Name on Card

Card Number

Month

Year

Code

Billing Email

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Contact Information