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* 1. First and Last Name

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* 2. D/O/B:

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* 3. Email address:

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* 4. Cell Phone Number [ex. (area code)-123-4567]

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* 5. Do you live in Detroit?

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* 6. Address

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* 7. How many family members, including yourself, do you currently live with?

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* 8. How would you describe your ethnic group? (select all that apply)

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* 9. Please specify your gender

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* 10. What is your marital status?

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* 11. What is the highest level of school that you have finished?

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* 12. What is your household income?

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* 13. What language are you most comfortable speaking?

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* 14. What is your current work situation?

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* 15. Do you participate in any of the following programs? [Select all that apply]

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* 16. How did you hear about the program?

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* 17. Select your preferred Brilliant Detroit Neighborhood Hub

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* 18. Please select the session you would like to attend.

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* 19. Have you participated in this program before?

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* 20. Do you understand that an onboarding session is required before the program begins, in which you will visit for a quick intake of metrics (weight, blood pressure, receiving the curriculum, etc.) THIS SHOULD NOT TAKE MORE THAN 15-20 MINS.  

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