Demographics Survey

All information provided remains confidential and is required for funding information or is collected to help our program to improve services and better understand the needs of those we serve.

Name

First Middle Last

Date of Birth

Marital Status

Gender

Primary ethnic origin

Secondary ethnic origin

Health Insurance

Highest Level of Education Completed

Employment Status

Monthly Household Income

Include income for all members of the household

What County Do You Live In?

Ex. Boone, Adair, Cole

What City Do You Live In?

Ex. Columbia, Centralia, Jefferson City

Has anyone in the household been homeless in the last 3 years?

Yes

Have any members of the household been incarcerated?

Yes

How easy is it for you to find transportation to games?

Why does your child need this program?

ELECTRONIC SIGNED CONSENT

My electronic signature signifies that everything listed above is correct and true to the best of my knowledge. And that I permit you to enter my personal information into a Client Data Management System.

First Middle Last