Community Co-Designer Application 

Thanks for applying to be a community co-designer. Please fill out te form below. When you have done so, click submit. The form will be sent to Family Service Rochester. We will follow up with you by email or phone. 
Name:
Street Address:
City:
State:
Zip:
Email:
Phone:
Date of Birth (day/month/year):
Do you receive services from a nonprofit, County, or other agency?:
Do you identify as Black, Indigenous, or Person of Color (BIPOC)?:
Do you provide care for a low-income elder or a BIPOC elder :
Which in-person meeting schedule do you prefer?:

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