Name (stage name is fine for now) *

First Name

Last Name

Phone Number

(###)

###

####

Which most closely describes your race

Black or African American: A person having origins in any of the Black racial groups of Africa

Indigenous, Native American or Alaska Native: A person having origins in any of the original peoples of North and South America (including Central America) and who maintains tribal affiliation or community attachment

Asian: A person having origins in any of the original peoples of the Far East, Southeast Asia, or the Indian subcontinent including, for example, Cambodia, China, India, Japan, Korea, Malaysia, Pakistan, the Philippine Islands, Thailand, and Vietnam

Native Hawaiian or Other Pacific Islander: A person having origins in any of the original peoples of Hawaii, Guam, Samoa, or other Pacific Islands.

Latinx: A person of Latin American cultural or ethnic identity in the United States.

White-passing: A person who identifies as a person of color who is very light skinned. Please select this option if you do not wish to be given priority due to privilege.

White: A person having origins in any of the original peoples of Europe, the Middle East, or North Africa.

Other*

Biracial

Multiracial

Unknown*

Which of these best reflects your current gender identity? *

Transgender female

Cisgender (born assigned) female

Transgender male

Cisgender (born assigned) male

Gender nonconforming/Nonbinary/Agender

Genderqueer

Two-spirit

Prefer not to say

Other*

What are your pronouns? *

She/her

He/him

They/them

Zi/zir

Other*

Which of these best describes your sexual orientation?

Lesbian/gay

Queer

Bisexual/pansexual

Asexual

Straight

Prefer not to say

Other*

Are you currently an erotic service provider? *

Including but not limited to: Nude or partially nude entertainer, digital erotic content, in person services, adult massage, camming, dominatrix or other BDSM services

Yes, I am currently a full time erotic service provider.

Yes, I am currently a part time erotic service provider.

No, I am not currently an erotic service provider.*

Between March 2019 and March 2020 (before COVID) did you earn the majority of your income as an erotic service provider? *

Yes

No*

Do you currently have custody of children under the age of 18?

Yes*

No

Are you currently behind on rent or utilities payments?

If you are behind, indicate how much you owe below.

No, I do not currently owe rent or utilities

$1-$499

$500-$1,999

$2,000-$4,999

$5,000-$9,999

More than $10,000

Are you currently experiencing houselessness?

Yes, I am currently houseless

No, but I am at risk of becoming houseless in the near future

No, I am not currently houseless

Are you currently experiencing or at risk of domestic violence?

Yes, I am currently experiencing or at risk of domestic violence.

No, I am not currently experiencing or at risk of domestic violence.

Prefer not to answer

Do you consider yourself to have any of the disabilities or learning difficulties listed in the following question?

Yes

No

If YES, please tick one or more of the following boxes:

Visual impairment (beyond the ability for glasses to correct)

Hearing impairment

Disability affecting mobility (wheelchair/mobility aid user)

Other physical disability

Emotional behavioral disability

Mental ill health

Temporary disability after illness

Moderate learning difficulty

Severe learning difficulty

Dyslexia

Dyscalculia

Other specific learning difficulty

Other (please specify)*

Would you like to be contacted when these services are available

please select all that apply from the following list

yes contact me

no do not contact me

Rental payment assistance

Yes

No

Utility payment assistance

Yes

No

Medical bills

Yes

No

Groceries/Food

Yes

No

STI testing

Yes

No

COVID-19 testing

Yes

No

Diapers/Wipes

Yes

No

Menstrual supplies

Yes

No

Legal support/representation

Yes

No

Harm reduction supplies

ie. clean sharps, shap disposal, narcan

Yes

No

Safer Sex supplies like condoms, lube, dental dams

Yes

No

COVID-19 Supplies (masks, sanitizer, testing, etc)

Yes

No

Can Haymarket Pole Collective contact you to collect an interview for promotional purposes?

Yes

No