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Community Interest Form: Demographics
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* Indicates required question
First Name
*
Your answer
Last Name
*
Your answer
Phone Number
Your answer
Email
*
Your answer
Gender
Female
Male
Non-binary
Prefer not to say
Other:
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Age
*
Choose
0 - 17
18 - 20
21- 30
31 - 40
41 - 50
51 - 65
65+
Ethnicity
*
Caucasian
African-American
Latino or Hispanic
Asian
Native American
Native Hawaiian or Pacific Islander
Two or More
Other/Unknown
Prefer not to say
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