Name *

First Name

Last Name

Phone *

(###)

###

####

Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

How would you describe your community? *

Urban

Suburban

Rural

Gender *

Female

Male

Transgender

Non-Binary

Prefer not to say

Race/Ethnicity *

Asian

Black or African American

Biracial/Multiracial

Indigenous American

Latino or Hispanic

Native Hawaiian or Pacific Islander

White or Caucasian

Age Range *

18-24

25-34

35-44

45-54

55-64

65 years or older

Party Affiliation *

Democrat

Republican

Independent

Other