SEPTEMBER EVENT Summer Shine Registration, CACSCW Madison Office

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?

Under $15,000

Between $15,000 and $29,999

Between $30,000 and $49,999

Between $50,000 and $74,999

Between $75,000 and $99,999

Over $100,000

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* 9. Languages comfortable speaking

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* 10. Veteran Status

Not a veteran

Veteran

Active military

Unknown

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* 11. Do you have a disability?

Yes

Prefer not to answer

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

Yes - first dose

Yes - second dose

Yes - booster

No - no vaccine

Prefer not to answer

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

1:00 pm - 1:30 pm

1:30 pm - 2:00 pm

2:00 pm - 2:30 pm

2:30 pm - 3:00 pm

3:00 pm - 3:30 pm

3:30 pm - 4:00 pm

Unknown

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* 14. Demographics: Race

White or Caucasian

Black or African American

Hispanic or Latino

Asian or Asian American

American Indian or Alaska Native

Native Hawaiian or other Pacific Islander

Another race

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* 15. Ethnicity

Hispanic or Latino Origins

Not of Hispanic or Latino Origins

Unknown