Demographic Information

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* 1. Are you receiving services or have you received services from Chautauqua Opportunities, Inc. or its programs in the past 12 months?

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* 2. How many people live in your household?

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* 3. What is your gender identity?

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* 4. What is the primary language spoken in your household?

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* 5. Are you of Hispanic, Latino or Spanish origin?

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* 6. What is your race?

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* 7. What is your age?

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* 8. What are the ages of the other people living in your home?

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* 9. Where do you live? Please enter your zip code below.

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* 10. Where do you live? Please enter your city/town/village information.

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* 11. What is the highest level of education you have completed?

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* 12. What have been your household's top THREE needs within the past 12 months. Check three that apply:

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* 13. Check ALL the services you or someone in your household needed but did NOT receive within the past 12 months. Check all that apply:

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* 14. If you needed services, but didn't get them, what was the reason?

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* 15. How did you hear about Chautauqua Opportunities, Inc.? Check all that apply:

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* 16. Which of the following do you or other members in your household use? Check all that apply:

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