Background

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* 1. Host organization name

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* 2. Today’s date

Date / Time

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* 3. What city do you live in? 

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* 4. How many children are in your household?

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* 5. What are the ages of children in your household?

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* 6. What is your primary language?

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* 7. Which category best describes you? (Please select all boxes that apply)

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* 8. What is your total annual household income?

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