NationSwell IM Intake Form

We always strive to keep our member information up to date so that we can best serve folks in meaningful ways. Thank you for completing the information below!

First name

Last name

Professional Email

Pronouns

Current Job Title

Assistant Name (if applicable)

Assistant’s Email (if applicable)

Bio

If you have not recently provided NationSwell with a short bio, please do so here:

Recent Headshot

Birthday Month

Birthday Day

Mailing Address (where you’d like to receive cards, personal gifts, etc.)

Race/Ethnicity

As part of our commitment to diversity, equity, and inclusion, we invite you to share additional information about yourself. All questions in this section are optional.

Gender Identity

As part of our commitment to diversity, equity, and inclusion, we invite you to share additional information about yourself. All questions in this section are optional.

Do you identify as LGBTQIA+?