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2. First Name *

   Insert first name here 

3. Last name *

   Type Full last name 

5. Address*
7. City
8. State
9. Zip Code*
11. Phone Number*
12. Age *
14. Email Address*
16. Ethnicity *

    Check the box that best applies to your race 

    1. Caucasian/White
    2. Black/African American
    3. Asian American
    4. Indian/Alaska Native
    5. Native Hawaiian/ Pacific Islander
    6. Non-White Hispanic
    7. Other
18. Occupation *

    If retired, student, disable or unemployed please specify:

19. Do you represent a organization, school, and or business?

    If yes, please list the name and if no, skip this question 

21. Highest Level of Education*

    1. Unfinished
    2. High School Dipolma/ High School Equivalency (GED etc.)
    3. Associates Degree
    4. Bachelors Degree
    5. Masters Degree
    6. Doctorate Degree
    7. Other/Certificate
22. Current Income Level *
    -- Select One --$0 - $16,321 $16,322 - $34,974 $34,975 - $41,968 $41,969 & Above

    Select one:

24. Are you interested in volunteer opportunities for the City of Buffalo?*
    -- Select One --YesNo

    Please select one:

25. Are you interested in a free training in Crime Prevention through Environmental Design(CPTED)? *
    -- Select One --YesNo

    This will allow for you to create a safety community development project to happen in your area with the opportunity for funding to make your design plan actionable

27. What dates are you available for the free CPTED training? *
    -- Select One --Delevan Grider Center - Jan. 16th, 17th & 18th (5:30pm - 7:30pm) Tosh Collins Center Feb. 21st, 22nd, & 2:30pm (5:30pm - 7:30pm)

    Please choose a date and an email will be provided as confirmation with location of training. Individual will receive a certificate of completion. 

28. Are you interested in having a free tree planted in front of your residence? (Between street and sidewalk) *
    -- Select One --YesNo

    This is being done to help the beautification of all neighborhoods throughout the city of Buffalo 

30. What specific street or area in the City of Buffalo besides your residence could use a tree planted?
31. Are you interested in forming or starting a block club?
    -- Select One --YesNo

    Choose one:

33. Are you available Friday's at 12:00pm to participate via online video chat in the City of Buffalo Community Block chat? *
    -- Select One --YesNo

    Choose one:

34. Is there a community organization/business that you may be aware of that can benefit the residents in Buffalo?

    Please list business name and contact information

36. What are some specific changes or concerns you may have about your community or within the City of Buffalo?
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38. 1. Receive an email copy of this form.
39. Email address

    This field is not part of the form submission.

40. Submit

* indicates a required field