Sage Upstate Demographics Form 
Sage Upstate Demographics Form
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Name *
Sage Upstate
All information will remain confidential and will only be used for SAGE mailings, emails, and record purposes.
Do you give permission for SAGE Upstate to use your name and image in our newsletter, website and social media posts? *
Yes
No
Social Media posts
Newsletter
Do you want to receive weekly email updates? *
Yes
No
Already receive
Emails
Email Address
Do you want to receive newsletters and/or mailings? *
Yes
No
Already receive
Newsletters and Mailings
Are you a veteran,  and if so in which branch did you serve?
Address
Do you want to receive Program reminders via Text. *
Please, provide phone number.
Birth dates will be used for demographics and with your permission will list month and day only in the newsletter.
Do you give permission to list month and day in the newsletter? (Year will not be posted but is needed for grant purposes) *
Yes
No
Permission
Birthday *
MM
/
DD
/
YYYY
Ethnicity
Prefer not to say.
Alaska Native
Asian American/ Pacific Islander
African America/ Black
Hispanic/ Latino
Native American
White
Other
Ethnicity
Clear selection
Sexual Orientation *
Prefer Not to Say
Gay
Lesbian
Bisexual
Queer
Heterosexual
Sexual Orientation
Gender  *
Required
Pronouns *
He, Him, His
She, Her, Hers
They, them, Theirs
Pronouns
Program -- Check all programs you are interested in attending *
Required
Submit
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