WZZM 13 is looking for West Michigan residents who might be interested in being interviewed, on camera, for local news stories. We might contact you to talk on topics ranging from child care to presidential politics. If you are interested, please fill out the form below. This information is for internal use only and it will NOT be shared with anyone else.

First Name:

Last Name:

City:

Income: pull downUp to $18,000$18,000 to $24,000$24,000 to $38,000$34,000 to $55,000$55,000 Plus

Times of the day You are available to talk to somebody?

How many people in your family?

Single parent family? YesNo

If the last answer was NO, do both parents work outside the home? YesNo

Hobbies. What do you enjoy doing in your free time?

Religion: pull downProtestantCatholicJewishIslamicOtherNone

Area code and Phone:

Email:

Age: (You must be 18 years old or older to register. If you are not 18, please have a parent or guardian register for you.)

Ethnicity: pull downWhiteAfrican-AmericanAsianHispanicNative AmericanOther