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Community Listening Session Registration
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1.
What is your first name?
(Required.)
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2.
What is your last name?
(Required.)
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3.
What is your email address?
(Required.)
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4.
I would like to join the following:
(Required.)
September 23, 2025 - ATCAA
| Early Childhood Family Listening Session 6:00-7:00pm
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5.
What is your affiliation with Behavioral Health/Public Health? (select all that apply)
(Required.)
Family member of youth or adult receiving or eligible for ACBH services
Adult or older adult eligible for ACBH behavioral health and/or substance use disorder services
Youth living in Amador County
Youth mental health or substance use disorder organization
Veteran
Health care organization, including hospitals
Health care service plans, including Medi-Cal managed care plans
Disability insurer
Public safety partner, including county juvenile justice agencies
Area agency on aging
Higher education partner (Amador College Connect, etc.)
Local education agency or school district
Early childhood organization
Amador County Public Health
Amador County Social Services
Independent living center representative
Homeless service provider, Continuum of Care representative
Provider of mental health services and substance use disorder treatment services
Tribal and Indian Health Program representative
Emergency medical services
Labor representative organizations
Community-based organization serving culturally and linguistically diverse community members
Regional center representative
Other (please specify)
None of the above
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6.
What age group are you in?
(Required.)
Under 18
18-24
25-34
35-44
45-54
55-64
65+
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7.
What is your race/ethnicy? (select all that apply)
(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 or Caucasian
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8.
What is your primary language?
(Required.)
English
Spanish
Other (please specify):
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9.
Do you think of yourself as:
(Required.)
Male
Female
Transgender Male/Trans Man
Transgender Female/Trans Woman
Nonbinary, neither exclusively male or female
Decline to Answer
Something else, please specify:
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10.
Do you think of yourself as:
(Required.)
Straight or heterosexual
Lesbian, gay or homosexual
Bisexual
Don't Know
Decline to Answer
Something else, please specify:
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11.
What city/town/area do you live in?
(Required.)
Amador City
Buckhorn
Camanche
Fiddletown
Ione
Jackson
Martell
Pioneer
Pine Grove
River Pines
Sutter Creek
Plymouth
Volcano
Other (please specify)