Needs Assessment

* 1. In what city do you live?

* 2. At what email address would you like to be contacted?

* 3. Which race/ethnicity best describes you? (Please choose only one.)

* 4. Please rank your child's needs from 1 to 5. 1-most important, 5-least important

* 5. What is your approximate average household income?

* 6. Which do you believe more money should be dedicated to? (Select One)

* 7. Does anyone in your household currently receive Medicaid benefits, or not?

T