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Seattle CiviForm
Note: Fields marked with a * are required.
The next questions are about your age, race, ethnicity, and language. Your responses help us build a better program. NOTE: Your answers will not impact whether you qualify for Fresh Bucks.
What is your age? *
18-29
30-39
40-49
50-59
60-69
70-79
80 or older
Prefer not to answer
Are there children under the age of 18 in the household? *
Yes
No
What is your race? *
Check all that apply
American Indian/Alaska Native
Asian
Black/African American
Hispanic/Latino of any race
Native Hawaiian/Other Pacific Islander
North African/Middle Eastern
White
What is your preferred language? *
We will send materials in the selected language whenever possible.