Skip to content

Local Focus Group Interest Form

1.Name (First & Last)

*2.Email Address(Required.)

3.Age

Under 18

18-24

25-34

35-44

45-54

55-64

65+

4.Please select your City/Town of residence

Other (please specify)

5.What is your race or ethnicity?

Asian

Black or African American

Hispanic or Latino

Middle Eastern or North African

Multiracial or Multiethnic

Native American or Alaska Native

Native Hawaiian or other Pacific Islander

White

Another race or ethnicity, please describe below

Self-describe below:

6.How did you hear about this opportunity?

7.Are you available to attend an in-person community discussion the week of July 28 in the evening?

Yes

No

Maybe

Powered by

See how easy it is to create surveys and forms.

Privacy & Cookie Notice