Roanoke County Registration 3/18/24 Contact Information Question Title * 1. Please Tell Us About Yourself: Your First Name Your Last Name Your Street or Mailing Address Your City Your State Your Zip Daytime Phone Evening Phone Email: Question Title * 2. How would you identify your race: Caucasian African American Native American Hispanic Asian Two or More Races Prefer Not to Answer Question Title * 3. Please Tell us About Your Ethnicity Not Hispanic Hispanic Prefer Not to Answer Question Title * 4. What is the Primary Language Spoken In your Home: English Spanish Other Question Title * 5. Are you the Parent of a Child with Disabilities ages birth to 26 (Includes Parent, Grandparent, Foster or Adoptive, Surrogate, or Relative of a Child with a Disability Yes No Next