* 1. Please provide each of the following:

* 2. Please answer the following (if applicable):

* 3. Has anyone in your household ever served in any branch of the United States military, or not?

* 4. Is anyone in your household currently serving in the United States military, or not?

* 5. Is anyone in your household a widow of a former veteran, or not?

* 6. Is anyone in your household a senior citizen?

* 7. Are you or is anyone in your household physically, mentally, or emotionally disabled?

* 8. How did you hear about our program?

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