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2. First Name*
3. Last Name*
4. Pronouns
6. Residential Address*
7. Occupation/Employer/Retired/School*
9. Email*
10. Primary Phone*
11. Other Phone
13. What is the best way to contact you if you are selected for an interview ?*
    -- Select One --TelephoneEmail
14. If appointed to the Active Transportation Committee, could you begin your term in January 2023?*
    -- Select One --YesNoMaybe
18. Optional Information

    The City of Eugene does not discriminate on the basis of race, gender, or other forms of demographic identity or expression. In order better evaluate the effectiveness of our recruiting efforts and ensure we consider the needs of all our community members, please consider the following optional questions.

20. Age
    -- Select One --1-1819-2526-3536-4546-5556-6566+
21. Residence
    -- Select One --RentOwnExperiencing Homelessness
23. Ethnicity

    Check as many as apply

    1. American Indian or Alaskan Native
    2. Asian or Asian American
    3. Black or African American
    4. Hispanic, Latino, Latina, or Latinx
    5. Middle Eastern or Northern African
    6. Native Hawaiian / Pacific Islander
    7. White
    8. Other
24. Ethnicity: If you selected 'Other', please decribe
26. Gender
    -- Select One --Non-BinaryFemaleMale
27. Gender: If you prefer to self-describe, please do
29. Household Income (annual estimate)
    -- Select One --Under $25,000$25,000-$50,000$50,000-$75,000Over $75,000
30. Do you identify with having a disability?
    -- Select One --YesNo
32. Languages you speak fluently

    Check all that apply

    1. Indigenous American
    2. American Sign Language
    3. Spanish
    4. Portuguese
    5. Chinese (Mandarin)
    6. Tagolog
    7. Korean
    8. Japanese
    9. Vietnamese
    10. Arabic
    11. French
    12. German
    13. English
    14. Other
33. Languages: If you selected 'Indigenous American' or 'Other', please describe
35. How did you learn about vacancies on the Active Transportation Committee?

    1. Newsletter
    2. City of Eugene Website
    3. Social Media
    4. Television
    5. Radio
    6. The Register Guard
    7. Eugene Weekly
    8. Email
    9. Word of mouth
    10. Other
36. How learned about vacancies: Part 2

    If you selected Newsletter, please indicate which one

    If you selected Social Media, please indicate which one

    If you selected Word of Mouth, please explain 

40. 1. Why is active transportation an important component of Eugene’s transportation system? How do you think improving conditions for active transportation on Eugene’s streets and shared-use paths could benefit the community and its members?*
42. 2. If you could change just one thing about the current active transportation environment in Eugene, what would it be? What are your ideas on how to realize that change?*
44. 3. Members of the Active Transportation Committee represent a broad range of interests. Please indicate areas of personal or professional experience, expertise or skills you would bring to the committee.

    Check all that apply

    1. Walking
    2. Bicycling
    3. Skateboarding
    4. Scooting
    5. Roller Skating/Blading
    6. Public Transit
    7. People with Disabilities
    8. Seniors
    9. Students
    10. Families
    11. BIPOC Communities
    12. Low Income
    13. LGBTQ
    14. Public Speaking
    15. Communication & Marketing
    16. Event Planning
    17. Fundraising
    18. Healthy Communities/Public Health
    19. Effective Advocacy/Community Organizing
    20. Environmental Justice/Climate Action
    21. Other
46. If 'Other,' note here:
48. 4. Describe how your personal experience and/or professional background will help you to be an engaged and informed member of the Active Transportation Committee. Include any details of your personal experience, community engagement (volunteering, board involvement, etc), academic and/or professional experience (vocational, skills training, degrees or certifications, licenses) you see as relevant to the interests you checked in the Question #3.*
50. 5. Please give examples of how you’ve engaged with the principles of equity and inclusion. Include any details of your personal, professional, or academic experience to support this, including any trainings (formal, informal, or self-study) you may have completed. *
52. 6. List any relevant organizations or groups of which you are a member and any boards, committees, or commissions to which you are appointed or have previously served. *
54. 7. Please give a specific example of how you helped navigate disagreement or conflict on one of these groups (or elsewhere).*
56. 8. Is there any other information related to your interest in serving as a member of Eugene’s Active Transportation Committee that you’d like to share?*
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58. 1. Receive an email copy of this form.
59. Email address

    This field is not part of the form submission.

60. Submit

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