1.Name (first and last optional):

*2.Race/Ethnicity (check all that apply):(Required.)

American Indian or Alaska Native

Asian

Black or African American

Hispanic or Latino

Middle Eastern or North African

Native Hawaiian or Pacific Islander

White

*3.Gender:(Required.)

Female

Male

Non-Binary

Prefer Not to Say

*4.Age:(Required.)

*5.City of Residence (zip code):(Required.)