Demographics (1 per participant)

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To help us better understand and serve our community, we kindly ask you to provide some basic demographic information. Sharing this information is completely voluntary and will be kept confidential. Your responses help us ensure our programs are inclusive, equitable, and responsive to the diverse needs of those we serve. Please fill out one form per child participant, Thank you.

Thank you for your support in helping us grow and improve!

What program are you a part of? Please feel free to select more than one. *

Beyond Divorce

Coordinated Services Team (CST)

Counseling

Family Steps

Parent Education & Support (PEAS)

Parents As Teachers (PAT)

Rainbows

School Based Services

Senior Services

The Incredible Years

Youth Groups

Other:

Required

Gender *

Male

Female

Transgender

Non-Binary

Prefer not to say

Other:

Required

Ethnicity *

African American / Black

Asian

Caucasian / White

Hispanic / Latino

MIddle Eastern

Multi-racial

Native American

Native Hawaiian

Other

Unknown

Required

Age Group *

0-3 years old

4-5 years old

6-11 years old

12-17 years old

18-24 years old

25-34 years old

35-44 years old

45-54 years old

55-64 years old

65-74 years old

75-84 years old

85-94 years old

95 & older

Required

Household Income *

$0 thru $9,999

$10,000 thru $14,999

$15,000 thru $24,999

$25,000 thru $34,999

$35,000 thru $44,999

$45,000 thru $54,999

$55,000 thru $64,999

$65,000 thru $74,999

$75,000 thru $84,999

$85,000 thru $89,999

$90,000 or more

Unknown

Required

Zip Code *

53004

53012

53021

53024

53074

53075

53080

53092

53097

Unknown

Required

Number of individuals served in the Armed Forces *

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