0-18 45-54 75-84 □ □ □ 19-34 55-64 85+ □ □ □ 35-44 65-74 □ □ Are you a Baby Boomer (born between 1946-1965)? Yes No □ □ Are you of Hispanic, Latino or Spanish descent? Yes No □ □ Which of the following best describes you? White Asian □ □ Black/African American Hawaiian/Pacific Islander □ □ American Indian/Alaska Native Two or more mixed race/color □ □ State where I live ______________________________________________ County in which I reside _________________________________________ Please list things that you do to embrace age and longevity (living a long time): Additional Comment
□ 0-18 □ 19-34 □ 35-44 □ 45-54 □ 55-64 □ 65-74 □ 75-84 □ 85+ Are you a Baby Boomer (born between 1946-1965)? □ Yes □ No Are you of Hispanic, Latino or Spanish descent? □ Yes □ No Which of the following best describes you? □ White □ Black/African American □ American Indian/Alaska Native □ Asian □ Hawaiian/Pacific Islander □ Two or more mixed race/color State where I live ______________________________________________ County in which I reside _________________________________________ Please list things that you do to embrace age and longevity (living a long time): Additional Comment