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2. City Life Application
4. Thank you for your interest in this four-week, nine-session, discovery filled journey of the faces, stories, and services within the City of Dubuque. We look forward to our virtual get together, sharing key information about our departments, and answering your questions. Please fill out the application below to get started.
6. City Life can accommodate up to 35 online participants. Registration deadline is Friday, March 19, 2021 at 5 p.m.
8. First Name*
9. Last Name*
11. Address*
12. Apt #
14. City*
15. State*
16. Zip*
18. Phone number*
19. E-mail address
21. Do you live or work within the Dubuque City limits?*

    1. Yes
    2. No
22. How do you prefer to receive information*

    1. E-mail
    2. Mail
    3. Text message
    4. Phone call
    5. Other (please indicate below)
24. Other method of communication
26. How did you hear about City Life?*
28. Check the box next to all the sessions you plan to attend. *

    1. April 1, 2021
    2. April 6, 2021
    3. April 8, 2021
    4. April 13, 2021
    5. April 15, 2021

    1. April 20, 2021
    2. April 22, 2021
    3. April 27, 2021
    4. April 29, 2021
30. Note: All sessions are scheduled from 6-8 p.m. The sessions are subject to change due to staff's responsibility to city services.
32. We want City Life to be available to everyone. Please let us know if interpretation services would be helpful to you:

    1. Yes, I would like interpretation services.
34. For other accomodations please call or e-mail:
    563-589-4190
    humanrgt@cityofdubuque.org
36. If selected, I will attend at least eight (8) of the nine (9) sessions:*
    -- Select One --I agreeI do not agree
38. I give City staff permission to use my image on official documents, social media, brochures and videos:
    -- Select One --I agreeI do not agree
40. NOTE: In accordance with the Iowa code, information provided in this application is part of the public records retained by the City of Dubuque.
42. We will announce participants by phone, e-mail and/or letter on or before Monday, March 22, 2020.
44. First Name*
45. Last Name*
47. Today's date:*
Leave This Blank:


49. 1. Receive an email copy of this form.
50. Email address

    This field is not part of the form submission.

51. Submit

* indicates a required field