I choose not to provide this information Community Name: Total # of members: Age Group # of Individuals Race/Ethnicity # of Individuals Child & Youth White (0-15) Transitional Aged African American Youth (16-25) Adult (26-59) Asian Older Adult (60+) Pacific Islander Native American Hispanic Multi Unknown Other Primary # of Individuals Culture # of Individuals Language English Spanish Veteran Vietnamese Other Cantonese Mandarin Tagalog Cambodian Hmong Russian Farsi Arabic Other IV Signature I hereby certify that the information contained herein is true to the best of my knowledge and understand that falsification of this information is grounds to be excluded from the Community Wellbeing Grant program. Project Leader Position/Role Name _________________________
I choose not to provide this information Community Name: Total # of members: Age Group # of Individuals Race/Ethnicity # of Individuals Child & Youth (0-15) White Transitional Aged Youth (16-25) African American Adult (26-59) Asian Older Adult (60+) Pacific Islander Native American Hispanic Multi Unknown Other Primary Language # of Individuals Culture # of Individuals English Spanish Veteran Vietnamese Other Cantonese Mandarin Tagalog Cambodian Hmong Russian Farsi Arabic Other IV Signature I hereby certify that the information contained herein is true to the best of my knowledge and understand that falsification of this information is grounds to be excluded from the Community Wellbeing Grant program. Project Leader Name Position/Role _________________________