Share Your Experience Form ACY.org

1) Your Information

First Name:*

Last Name:

E-mail:*

Cell:*

City:*

State:*

Zip:*

Languages Spoken:

English
Spanish
French

(In addition to English) Other:

Race/ Ethnicity:

American
Indian Native American, Alaskan American
Asian
Pacific Islander, East Asian, South Asian
Black
African American, Afro-Caribbean, African including North And Sub Saharan
Latino
Hispanic, Caribbean, Mexican, South and Central American
White
Other

2) Preferences

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Please share the information I have provided above, and share my email address with the media. (It's super important that we find people who can speak to the media.)
Please share the information I provided above, except for my email address & last name. (Please DO NOT check this box if you checked the box above.)

3) Your Story

Story Topic*

Story Title:*

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Your Story:*

4) Terms of Use

By checking this you are indicating that you have read and agree to the ACY terms of use and content submission agreement. You must accept our terms of use in order to submit.

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I agree