Engaged Neighbor Packet Request Survey

Thank you for your interest in the Engaged Neighbor Program offered by the Greene County MU Extension Council. Please complete this short questionnaire. Once a week David Burton will mail out our popular 130-plus page informational packet to those that have completed this survey. The packet is provided for free. But this survey information is vital to the continued success of our program.

*1.Please provide your basic contact information.(Required.)

Your name:

Company or Organization:

Address:

City, State AND Zip Code

Phone number:

Email address:

We are required to ask basic demographic questions of all program participants because of our funding from USDA.

2.Please select your gender:

Male

Female

3.Please select if you are Hispanic or Latino

Yes - Hispanic or Latino

No I am not

*4.What race do you identify with? (Only select one)(Required.)

American Indian or Alaskan Native

Black or African American

White

Asian

Native Hawaiian or Pacific Islander

Two or more races

Some other race

I prefer not to disclose

*5.Are you a veteran?(Required.)

Yes

*6.Are you disabled?(Required.)

Yes

*7.Why do you have an interest in neighboring?(Required.)

*8.Do you have goals or plans related to neighboring in the coming year?(Required.)

*9.Is there a person, a program, a city or book related to this idea of neighboring that you think we should be aware of for future classes? If so, please provide us with complete information.(Required.)

*10.Is there a way that the #engagedneighbor network can be of assistance to you and your neighboring plans? If so, please describe.(Required.)

*11.How did you hear about MU Extension's Engaged Neighbor program?(Required.)

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