Demographic Data Race: American Indian or Alaska Native Asian Hawaiian or Other □ □ □Native Pacific Islanders Black or African American (Non-Hispanic) race □ □Hispanic/Latino □White □Other Pacific Islander Refused to report □Other □Unreported/ Ethnic Group: or Latino Hispanic or Latino to report □Hispanic □Not □Refuse Country of origin? China Colombia Cuba □USA □ □ □ □ Egypt El Salvador Honduras Iran Iraq □ □ □ □ □ □Vietnam Mexico Syria □Jordan □Lebanon □Malaysia □ □ □Thailand □other______ Employment Status: time time Employment □Full □Part □Self □Retired □Unemployed Student Status: time time in school □Full □Part □not Are you a Veteran? □Yes □No Are you a season worker? □Yes □No Are you a migrant worker? □Yes □No Are you homeless? □Yes □No Are you a refugee? □Yes □No Are you a U.S Citizen? □Yes □No Are you Pregnant? □Yes □No What county do you live in? Bend □Harris □Ford □Galveston □Brazoria □Other_____________ Your age range □0-10 □11-19 □20-39 □40-49 □50-64 □65+ You may receive a discount if you qualify, please provide your income information. Family size:______________________ Total monthly income:____________________ how did you hear from us? □ Family/Friends □ □Community □Other_____________ Radio /TV event
Demographic Data Race: □ American Indian or Alaska Native □ Asian □Native Hawaiian or Other Pacific Islanders □ Black or African American □Hispanic/Latino □White (Non-Hispanic) □Other race □Other Pacific Islander □Unreported/ Refused to report Ethnic Group: □Hispanic or Latino □Not Hispanic or Latino □Refuse to report Country of origin? □USA □ □ China □ Colombia □ Cuba □ Egypt □ El Salvador □ Honduras □ Iran □ Iraq □Vietnam □Jordan □Lebanon □Malaysia □ Mexico □ Syria □Thailand □other______ Employment Status: □Full time □Part time □Self Employment □Retired □Unemployed Student Status: □Full time □Part time □not in school Are you a Veteran? □Yes □No Are you a season worker? □Yes □No Are you a migrant worker? □Yes □No Are you homeless? □Yes □No Are you a refugee? □Yes □No Are you a U.S Citizen? □Yes □No Are you Pregnant? □Yes □No What county do you live in? □Harris □Ford Bend □Galveston □Brazoria □Other_____________ Your age range □0-10 □11-19 □20-39 □40-49 □50-64 □65+ You may receive a discount if you qualify, please provide your income information. Family size:______________________ Total monthly income:____________________ how did you hear from us? □ Family/Friends □ Radio /TV □Community event □Other_____________
ENG-ADULT-REG.docx