Fatherhood Inclusion Form Demographics Question Title * 1. What is your first name? Question Title * 2. What is your last name? Question Title * 3. What is your date of birth? Date of Birth Date Question Title * 4. What is your street address? Question Title * 5. In what city do you live? Question Title * 6. In what ZIP code is your home located? (enter 5-digit ZIP code; for example, 00544 or 94305) Question Title * 7. Do you live in Kentucky? Yes No Other (please specify) Question Title * 8. What Kentucky county do you live in? Question Title * 9. What is your home telephone number? Question Title * 10. What is your cell phone number? Question Title * 11. What is your email address? Question Title * 12. Which race/ethnicity best describes you? (Please choose only one.) American Indian or Alaskan Native Asian / Pacific Islander Black or African American Hispanic White / Caucasian Multiple ethnicity / Other (please specify) Question Title * 13. Which of the following best describes your current relationship status? Married Widowed Divorced Separated Single, never married Next
