PURE HARLEM SURVEY

PURE HARLEM SURVEY ! This survey will not qualify you or disqualify your Membership in Pureharlem. It is only instituted for us to better understand the needs of our Community without pressure. Registered Members receive 500 Loyalty Reward Points for it's completion. This survey is completely private and will not be shared with anyone as noted in our Privacy Policy..


1. What is your date of birth ? MM/DD/YYYY

2. Where are you located? ( Country, State, City )

3. Do you have a business ?
Yes No

4. Would you like to be engaged in business ?
Yes No

5. If yes, what kind ?

6. Name of your Business or Organization ?

7. When was the last time you were tested for Covid-19 ?
One Week ago Two Weeks ago One month ago Two months ago Never

8. Would you like to be tested for Covid-19 ?
Yes No

9. If NO, why not ?

10. What are you interested in? Select all that apply.
Volunteering Professional Development Mentoring Advocating Resources & Services Meeting People

11. Are you registered to vote ? https://www.elections.ny.gov/VotingRegister.html
Yes No

12. IF NO, why not ?

13. Other Organizational Memberships or Affiliations (Check all that apply)
Rainbow Push Coalition National Action Network New York AIDS CoalitionNew York City New York Urban League National Association Advancement Colored People Asian American FederationAssociation Neighborhood and Housing Development Bronx Clergy Roundtable Brooklyn TogetherClergy United for Community Empowerment Coalition for Asian American Children and Families Coalition of Behavioral Health

14. Other, NOT LISTED

15. What services do you need or would like to see Pure Harlem provide ?

16. Are you familiar with the Seven Principles of Kwanza ?
Yes No

17. Did you actually read TERMS?PRIVACY POLICY ?
Yes No

Contact Details

Name(*)

Email(*)

Phone




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