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Your Name
Your Email Address
Your Phone Number
Your Age Teenage20-3031-4041-5051-6061-7071-8081-90Over 90
Your Address
Your Occupation
How Do You Identify? Indigenous Black CanadianAfrican BlackBlack AmericanLatin American BlackOther Black
Your Status in Canada Refugee / Temporary ResidentPermanent ResidentCitizen
Any Political Affiliation in British Columbia? YesNo
What are the Most Pressing Issues to You as a Black Person Living in B. C.?
How Do You Want to Participate in this Summit? I'll Be Attending PhysicallyI'll Be Attending Remotely
Any Other Information? (enter below)
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