Name *

First Name

Last Name

Phone *

(Optional)

(###)

###

####

Age

18-24

25-34

35-44

45-54

55+

Prefer not to say

Ethnicity

Hispanic

Non-Hispanic

Prefer not to say

Race

American Indian or Alaska Native

Asian

Black or African American

Middle Eastern or North African

Native Hawaiian or Pacific Islander

White

Prefer not to say

1. Are you a resident of North Omaha? *

Yes

No

1. Are you able to commit to attending bi-monthly CAB meetings (held the first Friday of every other month) for a minimum of one year? *

Yes

No

2. Are you willing to engage with community members and organizations to represent CAB initiatives and gather feedback? *

Yes

No

3. Do you have access to transportation to attend in-person meetings and events? *

Yes

No. If not, we may be able to provide assistance such as bus vouchers or mileage reimbursement. Please let us know if you would require transportation support.

4. Are you comfortable using virtual meeting platforms (e.g., Zoom) if needed? *

Yes

No

1. Do you wish to receive an honorarium for your participation on the CAB? *

Yes. If yes, additional details will be provided upon acceptance to the board.

No

1. Do you consent to having a brief biography about you shared on our website? *

Yes

No

2. Do you consent to having your photo taken and shared on our website and promotional materials? *

Yes. If yes to either, please provide a short bio (or we can draft one based on your application responses).

No

Print Name *

First Name

Last Name

Date *

MM

DD

YYYY

*

By checking this box, I certify that the information provided in this application is accurate and true to the best of my knowledge. If selected, I agree to adhere to the expectations and responsibilities of the North Omaha Community Advisory Board.