Name *

First Name

Last Name

Phone *

(###)

###

####

With which gender do you identify? *

Female

Male

Non-Binary

Other

What is the highest level of education you have completed? *

High School or Vocational School

Some College

College Degree

Graduate Degree

What of the following ethnicities do you most closely identify with? *

Caucasian/White

African Amnerican/Black

Hispanic/Latino

Asian/Pacific Islander

Native American

Other

Which of the following describes your current marital status? *

Single

Married or living with partner

Separated/Divorced/Widowed

Other

Which of these categories best describes your total household income before taxes? *

Under $25,000

$25,000 – $34,999

$35,000 – $59,000

$60,000 – $74,999

$75,000 – $99,000

$100,000 – $149,000

Above $149,000

Do you have children? *

Yes

No

Do you own or rent your home? *

Own

Rent

Other

What is your work status? *

Full Time

Part Time

Retired

Student

Other