2. All applications will be reviewed to ensure diverse representation. Applications will close on September 17 and selected members will be notified on or before September 27. Please do not call about your application status.

4. Membership Requirements:
   • Must reside in Shelby County
   • Must be 16 years or older
   • Must attend 2 meetings per month (virtual until further notice)
   • Must participate in the monthly goal
6. First Name*
7. Last Name*
9. Email Address*
10. Cell Phone # (for texting)*
12. Zip Code*
13. Age Range*
    -- Select One --16-1718-3031-5051-7071+
15. I Am A: (Please Check All That Apply)*

    1. Teacher
    2. Healthcare Worker
    3. Grocery Store Worker

    1. Retiree or Senior
    2. Neighborhood Leader
    3. Warehouse Worker

    1. Parent of School-aged Child
    2. High School Student
    3. College Student
17. Please Select Your Primary Language*
    -- Select One --EnglishSpanishASLFrenchGermanVietnameseChineseArabicOther
19. Would You Like to Share Your Facebook Profile*
    -- Select One --YesNoDon’t Have One
20. Facebook Profile Link*
22. Would You Like to Share Your Twitter Profile*
    -- Select One --YesNoDon’t Have One
23. Twitter Profile Link*
25. Are you a full-time resident of Shelby County, TN?*
    -- Select One --YesNo
26. Do you work in Shelby County, TN?
    -- Select One --YesNoRetiredStudentFurloughed/Unemployed
28. Meetings will take place twice per month and last approximately one hour. Meetings will be scheduled on weekdays in the afternoon. Are you able to commit to attend these meetings? *
    -- Select One --YesNoMaybe
30. Have you received or do you intend to receive COVID-19 vaccine? (information purposes only)*
    -- Select One --YesNoMaybe
32. Please describe why you’d like to join the COVID-19 Community Council.*
34. Please describe how you might contribute to the COVID-19 Community Council. This may include unique skills, strength, or perspective that may help guide our COVID-19 community response.*
Leave This Blank:


36. 1. Receive an email copy of this form.
37. Email address

    This field is not part of the form submission.

38. Submit

* indicates a required field