Change in YOUR Community Starts with YOU! Please Fill Out This Survey So We Can Help!

Please fill out the survey below so we can determine what really matters to you and your community.

“OUR POLITICS IS LOCAL”

Email
City, State, Zip Code*
Age
Ethnicity
Do you think artists, athletes and entertainers
should be more vocal about community issues?
 Yes 
 No 
Do you think what’s played on television, radio,
and the internet affects how people think and act?
 Yes, A lot  
 Yes, Somewhat 
 Yes, A little bit 
 No, Not at all 
What do you think of the job elected officials are
doing to address your communities’ needs?
*
 Excellent  
 Very Good  
 Okay  
 Not Good  
 Poor 
 Terrible 
Which elected office do you think has the most
impact on your community?
*
 President 
 Governor 
 State Representative/ State Senator 
 Mayor 
 Alderman 
Do you think voting makes a difference in your
community?
*
 Big Difference 
 Some Difference 
 Very Little 
 Not at All 
Do you consider yourself a member of the hip hop
generation?
*
 Yes 
 No 
Are you a registered voter?*
 Yes 
 No 
Did you vote in the last election?*
 Yes 
 No 
Please mark the top five areas you think are most
important to healthy communities.
 Youth and Families 
 Health and Wellness 
 Quality Education 
 Safety/Criminal Justice 
 Entertainment 
 Economic Development 
 Jobs and Employment 
 Human Rights 
 Media Justice 
 Environment and Renewable Energy 
 Affordable Housing 
Please mark the top five community issues you
think should be dealt with right away.
 Violence 
 Radio and Television Content 
 Jobs and Unemployment 
 Quality Schools 
 Access to Health Care 
 Access to Healthy Foods 
 Programs for Youth 
 Programs for Ex Offenders 
 Affordable Housing 
 Loans for Small Businesses 
 Support for Parents/Children 
 Police Misconduct/Bad Cops 
 Drugs 
 Domestic Violence 
 Civic Participation 
 Low Police Activity 
 Graffiti 
 Burglary or Robbery 
 Gang Activity 
 Loud Music 
Would you be interested in helping to promote a
community agenda?
*
 Yes 
 No 
 Maybe 
Name
First Last
Phone Number
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