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2. The Worthington Citizens Academy is tentatively planned to begin on Wednesday, September 20, 2023.  

   The City of Worthington Citizens Academy is a seven-week program designed to help Worthington residents learn more about their city government and become more connected to their community. There is a maximum of 20 participants per class, selected on a first-come basis. If you are not selected, you will be placed on a waiting list for future sessions.

4. Name:*
6. Home Address & Zip Code*
8. Employer:
10. Work Address
12. Email:*
14. Do you Live and/or Work in Worthington?*

    1. YES
    2. NO
15. Years Living/Working in Worthington:
17. Day Phone Number:*
18. Evening Phone Number:
20. Do you give us permission to share your name and contact information with other members of the Worthington Citizens Academy?*

    1. Yes
    2. No
22. Voluntary Information
    Please Check the Relevant Selections:
24. Gender Identity

    1. Male
    2. Female
    3. Transgender Male
    4. Transgender Female
    5. Non-binary/non-conforming
    6. Prefer not to respond
25. Age:

    1. 18-20
    2. 21-29
    3. 30-39
    4. 40-55
    5. 56-65
    6. 66+
27. How did you hear about the Worthington Citizens Academy?*
29. Briefly state why you are interested in participating in the Citizens Academy*
31. Have you had any experience with the City of Worthington, such as serving on a Board or Commission, neighborhood association, or other organization? Please list experience:
Leave This Blank:


33. 1. Receive an email copy of this form.
34. Email address

    This field is not part of the form submission.

35. Submit Submit and Print

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