Thank you for volunteering to conduct the community health assessment survey on September 8th! Your participation is important in order to collect the information needed to accurately assess the health needs of the community.

Name (first and last):

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* Name (first and last):

Email address:

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* Email address:

Cell phone number:

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* Cell phone number:

Do you speak Spanish?

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* Do you speak Spanish?

Surveys will be completed by pairs of volunteers, who will drive themselves to the assigned neighborhoods. We will do our best to accommodate your requests from your responses below.
Are you able to drive yourself to the assigned neighborhood on September 8th? (If no, this does not prevent you from participating)

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* Are you able to drive yourself to the assigned neighborhood on September 8th? (If no, this does not prevent you from participating)

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