Community Action Coalition for South Central Wisconsin, 4101 E. Towne Blvd, Madison, WI 53704

September 26, 2022; 1:00 pm - 4:00 pm

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* 1. First Name

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* 2. Last Name

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* 3. Age

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* 4. Email

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* 5. Zip Code

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* 6. How many adults are in your household? (including yourself)

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* 7. How many children are in your household?

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* 8. What was your household income last month?

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* 9. Languages comfortable speaking

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* 10. Veteran Status

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* 11. Do you have a disability?

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* 12. Are you interested in receiving a vaccine for COVID-19?

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* 13. What time do you plan on arriving at the event?

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* 14. Demographics: Race

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* 15. Ethnicity

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