Alternate ROOTS Organizational Membership Form
"Pay What You Can" Period Active
NOT ACTIVE
ACTIVE
Free Membership
Organization Name
Date Established
First Name
MI
Last Name
First and last name will be shared with other visitors to the site.
Street (Home)
City (Home)
Postal Code (Home)
State (Home)
Please select...
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District Of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Puerto Rico
Virgin Island
Northern Mariana Islands
Guam
American Samoa
Palau
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)
Email
Are you affiliated with the organization
Please select...
Yes
No
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 Color
Person with a Disability
Lesbian
Gay
Bisexual
Queer
Trans
Gender non-conforming
Military
Youth
Formerly Incarcerated
Not Applicable/No Answer
How do you identify ethnically? (Please check all that applied)
American Indian or Alaska Native
Arab, Arab American, Middle Eastern
Asian
Black or African American
Hispanic or Latino
Native Hawaiian or Pacific Islander
Other
White
Indigenous, Native American, First Peoples
MENASAAPI (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 school
High School graduate
Some college
Associate's degree
Bachelor's degree
Master's degree
Doctoral or Professional degree
$0 Dues During Alternate ROOTS Free Membership Window.
ROOTS membership annual dues. PWYC (enter the amount you can pay)
Enter Amount (DO NOT type $)
Would you like to make a donation?
Yes
No
Amount
Would you like to donate a membership?
Yes
No
Each Membership is equivalent to $40
Number of memberships to donate.
Who should receive the donated membership(s)
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 Card
Check
Would you like to automatically renew your membership every year?
Yes
No
If you choose the "Yes" option we will automatically charge your Credit Card $40 every year to keep your membership active.
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