Alternate ROOTS Membership Renewal Form

Membership Type

General - $40/yearVoting - $40/yearOrganizational - $40/year

If organization membership enter organization's name:

First Name

Last Name

What is your date of birth?

MM/DD/YYYY

Home Number

Cell / Mobile Number (with text capabilities)

Billing Address

Street

City

Country

States

Postal Code

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? (Check all that apply)

Arab, Arab American, Middle EasternAsian, Asian AmericanBlack, African AmericanIndigenous, Native American, First PeoplesLatinx, HispanicNative Hawaiian, Pacific IslanderWhite, EuropeanWrite In OptionMENASAAPI (Middle Eastern, North African, South Asian, Pacific Islander)

Write in Option

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)?

MemberFee

Donated Membership Total

Total Amount Due

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

How would you like to pay for your membership?

Credit Card (for PWYC renewal, donated memberships, and donations)Check (for PWYC renewal, donated memberships, and donations)

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