1.Name:

2.E-mail:

3.Phone Number:

4.Ethnicity:

White or CaucasianBlack or African AmericanHispanic or LatinoAsian or Asian AmericanAmerican Indian or Alaska NativeNative Hawaiian or other Pacific IslanderAnother race

5.Sex:

MaleFemaleNonbinaryOther

6.Age of Participant:

3-67-1213-1819-2526-3536-4748 and Over

7.Community in which participant lives:

Arlington HeightsBartlettBuffalo GroveElk GroveHanover ParkHoffman EstatesInvernessMt. ProspectPalatineProspect HeightsRolling MeadowsSalt CreekSchaumburgSouth BarringtonStreamwoodWheelingRiver TrailsOther (please specify)

8.Please select the NWSRA programming space for which you would like to provide feedback:

Buffalo Grove

Hanover Park

Mt. Prospect

Rolling Meadows

Wheeling

Hoffman Estates

Admin Offices at Rolling Meadows Park Central