Senior Citizen Program Demographics Form
First Name
Last Name
Date of Birth
Gender
Female
Male
Non-binary
Other
Prefer not to say
Ethnicity
White
Black or African American
Asian
Native American or Alaska Native
Native Hawaiian or Other Pacific Islander
Hispanic or Latino
Other
Prefer not to say
Street Address
City
State
ZIP Code
Phone Number
Email Address
Living Arrangement
Live Alone
Live with Family
Assisted Living/Nursing Home
Other
Annual Income Bracket
Less than $20,000
$20,000 - $40,000
$40,000 - $60,000
More than $60,000
Prefer not to say