General Membership Form
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First Name
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Last Name
First and last name will be shared on our membership directory.
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State (Home)
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Virginia
Washington
West Virginia
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Wyoming
Puerto Rico
Virgin Island
Northern Mariana Islands
Guam
American Samoa
Palau
Country (Home)
To better connect you with ROOTS members in your area, your state and country of residence will be shared on our membership directory and you will also be added to our state-by-state listservs.
What is your date of birth?
MM/DD/YYYY
Home Phone
Cell / Mobile Phone (with text capabilities)
Email
Preferred Contact Methods?
(select all that apply)
Phone
Email
Text Message
Mail
None of the above
Are you affiliated with an organization
?
Please select...
Yes
No
Other
What is its name?
Explain.
How do you feel your work aligns with the Alternate ROOTS mission? (
255 character MAX
)
255 characters left.
Please describe your work in the world, the art that you make, and / or tell us your personal mission statement. (
255 character MAX
)
255 characters left.
How did you hear about Alternate ROOTS?
ROOTS Member
ROOTS Staff
Executive Committee Member
General Word of Mouth
Social Media
Website
E-blast
Other
Been around ROOTS for a while
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? (Check all that apply)
American Indian or Alaska Native
Arab, Arab American, Middle Eastern
Asian
Black or African American
Hispanic or Latino
Indigenous, Native American, First Peoples
Native Hawaiian or Pacific Islander
Other
White
MENASAAPI (Middle Eastern, North African, South Asian, Pacific Islander)
Write In
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
Have you attended a ROOTS event before?
Yes
No
$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)
Membership Fee
Membership Due/PWYC
Donated Membership Total
Recurring Membership Amount
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
(for memberships and donations)
Check
(for memberships and donations)
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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