Demographic Information

Thank you for your interest in participating in Alliance for Children and Families Health Program! To get started, please share a little bit about you and your family with us.
Once you complete this survey, please return to the Health Website where you can participate in the activities!

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* 1. What is your first and last name?

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* 2. What is your age?

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* 3. What is your race or ethnicity?

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* 4. Are you currently a resident in one of Alliance for Children and Families Housing Programs? (e.g. Alliance Emergency Residence, A-First, B-First, or SOHO)

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* 5. How many others are in your household?

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* 6. If you have children, please list gender and age for each child. Otherwise, skip to the next page.

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