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* 1. What is your age?

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* 2. What is your ethnicity? Choose One.

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* 3. What gender do you identify as? Choose One. 

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* 4. Do you need assistance with any of the following aspects of your life?

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* 5. How has Covid-19 impacted you and your life? Choose all that apply:

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* 6. Would you like to receive more information about the Roads of Independence young adult program? If yes, put your first and last name, email address, and phone number below. If no, put N/A.

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