Oregon Recovers Registration Form Thank You For Joining the Movement! By filling out this form you agree to receive communications from Oregon Recovers. Oregon Recovers respects your privacy and will never sell, rent or share your contact information without your express permission. First Name: Last Name: Organization Affiliation: Email: Phone: (eg. 555-555-5555) Can we text you? Yes, you have permission to text me. No, you don't have permission to text me. Address: City: State: Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming American Samoa Federated States of Micronesia Guam Marshall Islands Northern Mariana Islands Palau Puerto Rico U.S. Minor Outlying Islands Virgin Islands Armed Forces Americas Armed Forces Europe, the Middle East, an Armed Forces Pacific Alberta British Columbia Manitoba New Brunswick Newfoundland and Labrador Nova Scotia Northwest Territories Nunavat Territory Ontario Prince Edward Island Quebec Saskatchewan Yukon Territory Zip: - Do you identify as any of the following (check all that apply) Person In Recovery Friend or family member of a person in recovery I work in recovery services, health care or behavioral health Other Prefer not to say Are you interested in volunteer opportunities? Yes No We collect demographic information so we can best support Oregon's diverse recovery community. If you do not wish to share you information, please select "Prefer not to say". What is your age? Under 18 years old 18-24 years old 25-34 years old 35-44 years old 45-54 years old Over 55 years old Prefer not to say To which gender do you most identifty Female Male Non-Binary Genderqueer Prefer not to say Other/Not Listed To which sexual orientation do you most identify? Heterosexual Gay/Lesbian Bisexual/Pansexual Asexual Queer Prefer not to say Other/Not Listed What is your race/ethnicity? (check all that apply) American Indian or Alaska Native Asian or Asian American Black or African American Hispanic or Latinx Native Hawaiian or Other Pacific Islander Middle Eastern, North African or Arab American White or European American Prefer not to say Other/Not Listed NeonCRM by Neon One
