Ten-Minute Men Sign-Up Form

Your Name (required)

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Are you already on the GiN distribution list? Note: This would mean you receive email directly from GiN periodically.: (required)
YesNo

Are you subscribed to the GiN website?
Yes, through emailYes, through RSSNo

How did you find about about Grassroots in Nebraska:
Have been involved for a whileFound through an internet searchAttended a Tea PartyAttended another eventSaw a report on TVReferred by a friend or familyRead about in newspaper

Please tell us some of the primary reasons you have become motivated to get involved in having an impact on government:

Please list the 5 top issues you believe are currently confronting government at all levels:

Which level of government do you find the most interesting? Note: It's not important whether or not you have a deep knowledge of these areas. You will notice that the federal government is not listed here. Grassroots in Nebraska is focused on state, county, and local government because we believe these are the levels of government we are most likely to impact.:
State Legislative BranchState Executive BranchCountyCity CouncilCity MayorSchool BoardPublic UtilitiesUniversity of Nebraska

Please list your current profession. Examples: attorney, data entry clerk, delivery driver, accountant, IT tech, receptionist.:

Please generally describe (or name if you're comfortable) any civic or church organizations of which you're a member. Examples: Knights of Columbus, church council member.:

Are you an active member of a political party? (Active meaning participating in party functions and activities besides voting.)
Yes, registered and activeNo, I am registered as IndependentNo, registered but not activeNo, I am not registered to vote

Are you an "official member" of any other activist group?
NoYes

Do you hold any official positions in a political party, activist group or civic organization?
YesNo

If you answered "yes" to the question above, please list your position and generally note the kind of group (i.e. political party, activist group, civic organization):

Is it important to you to remain anonymous regarding your involvement with the GiN group?
YesNo

If you answered "yes" to the question above, please briefly explain why.For instance, is it out of concern for your employment or membership in a union or business relationships?:

Considering your computer abilities, would you say you are:
Barely able to browse!AverageAdvancedExpert

If you listed "Advanced" or "Expert" above, please give a brief description of some of your computer skills:

What kinds of activities sound interesting or fun to you?:
Talking to people face to faceTaking picturesSetting up equipmentDesigning printoutsBuilding ThingsPlanning a partyCookingTracking data in a spreadsheetReading books/documentsMaking phone callsStrategic planningRunning errandsSolving ProblemsResearching online

The following questions are to help us route and target information appropriately:

What Nebraska Legislative District are you in? Please list the number of your district OR the name of your Senator if the number is not known. To learn which district you are in, please do the following:

• Open a new tab in your browser. IMPORTANT! If you do not open a new tab, when you click on the link, you will leave this page and lose all of the information you have entered!
• Click on the link provided and follow the "Find Your Senator" instructions: CLICK HERE

If you cannot figure out what legislative district you are in, either enter your street address in the box below and we will look up the information for you or enter "I don't know" and skip to the next question:

Please list your zip code. (Note: Zip code information helps us route information concerning other political districts.):

Please list your preferred phone number and indicate whether it is a home or cell phone and best time to call. (Please note: We do not conduct calling frequently. Periodically, we have the most expeditious form of communication is by phone.):

Please use the space below to make any additional comments or to ask any questions:

Please confirm that you are a human and not a spambot by solving this simple math equation. Thanks ;-)
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