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Diversely Segregated Interest Form
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Your Name
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Phone
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Email Address
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Zipcode / District You Currently Live In
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Why Are You Interested in Being on Diversely Segregated with Jerome Moore?
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What Makes You a Get Guest for Diversely Segregated ?
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How did you hear about us?
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Social Media
Referred by someone
Anything else your would like to add?
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Would you be willing to answer demographic questions to help us identify our audience?
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No, Thank You
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What is your age range?
18-25 years old
26-33 years old
34- 44 years old
45-52 years old
53- 60 years old
60+ years old
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How do you identify your gender?
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Female
Non-Binary
Other:
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What is your ethnicity/race?
White/Caucasian
Hispanic/Latino
Black/African American
Native American/ American Indian
Asian/ Pacific Islander
Other:
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What is your current employment status?
Employed full-time (40+ hours)
Employed part-time (less than 40 hours)
Unemployed (looking for work)
Unemployed (not looking for work)
Student
Retired
Self-employed
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What is your marital status?
Single
Married
In a domestic partnership
Divorced
Widowed
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What is the average income of your houshold/family?
Below $20k
$20k- $29.9k
$30k- $39.9k
$40k- $49.9k
$50k- $59.9k
$60k- $69.9k
$70k- $79.9k
$80k- $89.9k
$90k- $99.9k
$100K+
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