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First Name*

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Last Name*

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Title (if applicable)

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Organization (if applicable)

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Email*

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How did you hear about this class or event?*

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Please specify:

Tri-County Health Network’s programs are funded through grants from different agencies and foundations. To continue to receive funding and offer services in our community, we have to report on the demographics of the people served in our programs. Please help us learn more about our program participants by answering the following questions. You may select “choose not to answer” if you do not wish to provide the information. Thank you!

Click to Enter Demographic Info:

What gender do you identify with?*

What race do you identify yourself as?*

Please specify your ethnicity.*

What language are you most comfortable speaking?*

What is your veteran status?*

What type of health insurance do you have?*

What is your current employment status? *

What is the highest grade or year of school you have completed?*

How would you rate your personal/family’s financial situation? *

What is the total income for your household per year?*

How many people, including yourself, do you live with?*

What town/city do you live in?*

Please select which event you are registering for:*

Please tell us how many people (including yourself and kids) you will be bringing?

Who are you?

Do you have children under the age of 18 living with you?

What interests you about the topic of this film?*

Are there specific topics that you would like to address in the post-film discussion?

Who are you?

Do you have children under the age of 18 living with you?

What interests you about this topic? (Use the Ctrl button to select multiple responses)*

Are there specific topics that you would like to address in the discussion?