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of WarmLine Family Resource Center Family Survey/ Encuesta Familiar 2026
*
1.
First Name
Nombre
(Required.)
*
2.
Last Name
Appellido
(Required.)
*
3.
Telephone Number/ número de teléfono
(Required.)
*
4.
City of Residence/ ciudad de residencia
(Required.)
*
5.
Zip Code/código postal
(Required.)
6.
County/ condado
Sacramento
Placer
Yolo
El Dorado
Nevada
Alpine
7.
E-mail/correo electrónico
*
8.
Primary Language at home?/ idioma principal en casa
(Required.)
English
Spanish
Other (please specify)
*
9.
I am answering this survey as a/Estoy respondiendo a esta encuesta como
(Required.)
Parent or Guardian of child/ren with special needs/Padre de un niño con necesidades especiales
Relative ( sibling, grandparent, aunt/uncle of an individual with special needs)/Hermano, abuelo, familiar de una persona con necesidades especiales
Other (please specify)
*
10.
Which race/ethnicity best describes you?/¿Qué raza o etnia te describe mejor?
(Required.)
American Indian or Alaska Native
Asian or Asian American
Black or African American
Hispanic or Latino
Middle Eastern or North African
Native Hawaiian or other Pacific Islander
White
Multiracial/Biracial
race/ethnicity not listed here
Other (please specify)
*
11.
Which gender best describes you?/¿Qué género te describe mejor?
(Required.)
Male
Female
Other (please specify)
*
12.
Would you like to be added to WarmLine's E-newsletter?/¿Quieres que te agreguemos al boletín electrónico de WarmLine?
(Required.)
Yes
No
I am already signed up.
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