1.Please fill out the following so we may contact you.

Name

City/Town

State/Province

ZIP/Postal Code

Email Address

Phone Number

2.What is your age?

3.What is your gender?

Male

Female

4.How would you describe your ethnicity?

White

Black or African American

Hispanic or Latino

Asian or Asian American

Other (please specify)

5.How would you describe your household?

I live alone or with friends

I live with a partner or spouse, with no kids

I have children at home, including a baby aged 0-6 months

I have children at home, including a baby aged 6-12 months

I have children at home, including a baby aged between 12 and 36 months

I have children at home and they are all over 36 months old

My children have grown up and moved out