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若要查看中文版表格，請在頁面頂端選擇「中文」。
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هذا النموذج باللغة العربية، اختر "العربية" أعلى الصفحة. 
Para tingnan ang form na ito sa Filipino, piliin ang "Filipino" sa itaas ng pahina.
ដើម្បីមើលទម្រង់បែបបទនេះជាភាសាខ្មែរ សូមជ្រើសរើស "ភាសាខ្មែរ" នៅផ្នែកខាងលើនៃទំព័រ។ 
이 양식을 한국어로 보려면 페이지 상단의 "한국어"를 선택하십시오.

 

Hello!

You are one of 20,000 households in Oakland with a chance to enter a democratic lottery, to potentially take part in this unique process. If you are selected in the lottery, you will be one of 40 Delegates to serve on the Oakland Civic Assembly. 

Please complete a separate form for each member of your household who is 16 years of age or older. At the end of this form, you will be asked if you would like to complete another form for another member of your household.

Key Details

  • Deadline to respond: Thursday, July 17th
  • When: Three weekends – 9AM to 4:30PM each day
    • Saturday & Sunday, August 22-23
    • Saturday & Sunday, September 12-13
    • Saturday & Sunday, October 3-4
  • Stipend: $1,350 (equivalent to approx. $30/hour)
  • Other Support: Meals will be provided on Assembly days, as well as reimbursements for transportation, childcare, eldercare, and other personal assistance needs. If you are selected, language interpretation and translation, as well as any other accommodations will be arranged.

How to Respond to the Assembly Invitation

To be considered, complete the response form below. For questions or assistance filling out the form, please contact Healthy Democracy:

info@healthydemocracy.org
(510) 757-1715

 

 

Oakland Assembly Response Form

You may reply for multiple members of your household at the same time, as long as they live with you at the address on the postcard.

*
(including yourself)
-

Healthy Democracy (HD) will never give or sell your personal information to any other organization or government agency for any reason, except with your express written permission. Only your first name will be used during the Assembly. Your information will stay private to HD and its project staff.

You'll find this code printed on the inside of the postcard you received.

Contact Information

Only your first name (or a nickname) will be used publicly during the Assembly.
If you received this invitation from a social service agency or nonprofit, please type their name in the Street Address field above.

Personal Information

The following information will be used to select an Assembly that is representative of the people of Oakland. This "democratic lottery" is one of the unique aspects of civic assemblies. The lottery is randomized, anonymous, and representative – creating a sort of "city in one room."

My household . . . *
Age *
 
 

The options below are based on those currently used by the US Census. We recognize that identity is complex and that Census categories don’t capture everyone's background well. Please select the option that you would have answered on the Census.

Ethnicity *
Race *
*Note: Although "Middle Eastern & North African" is planned as a future US Census category, the most recent Census encouraged MENA respondents to mark "White."
Highest education level attained *
Language Spoken at Home *

Confirmations

Availability *

Saturday & Sunday, August 22 & 23
Saturday & Sunday, September 12 & 13
Saturday & Sunday, October 3 & 4

All six days of the Assembly will take place at a location near the Fruitvale BART station.

Eligibility *
Authorization to Contact *
Confirmation *