PARTICIPATION FORM
*
How did you hear about us?
Previous Participant
Craigslist.org
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Friend / Relative
Newspaper / Magazine
Website
If referred by a Friend or Relative, enter their Name and E-mail below so they get credit.
Referring Friend / Relative Information:
Friend / Relative First Name:
Friend / Relative Last Name:
Friend / Relative E-mail:
Contact Information:
* First Name:
* Last Name:
* Home Phone:
Work Phone:
Cell Phone:
* Email:
Please enter only one e-mail address.
Address:
City:
State:
Zip Code:
County:
Demographic Information:
* Date of Birth:
Month
January
February
March
April
May
June
July
August
September
October
November
December
Day
1
2
3
4
5
6
7
8
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21
22
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24
25
26
27
28
29
30
31
Year
2011
2010
2009
2008
2007
2006
2005
2004
2003
2002
2001
2000
1999
1998
1997
1996
1995
1994
1993
1992
1991
1990
1989
1988
1987
1986
1985
1984
1983
1982
1981
1980
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1978
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1945
1944
1943
1942
1941
1940
1939
1938
1937
1936
1935
1934
1933
1932
1931
1930
1929
1928
1927
1926
1925
1924
1923
1922
1921
1920
* Gender:
Male
Female
* Race:
Asian, Pacific Islander
African American
Caucasian
Hispanic
American Indian, Eskimo
Other
Unknown/Refused
* Education:
0-8th Grade
Some High School
High School Grad./GED
Some College
College Grad.
Advanced Degree
Employment status:
Full-time
Part-time
Student
Homemaker
Retired
Not employed
Occupation:
Administrative/ Coordinator
Blue Collar
Caregiver
Clerical
Computers/IT
Customer Svc
Education
Government
Homemaker
Legal
Manager
Marketing
Medical-Doctors
Medical-Non Doctors
Military
Retired
Self-Employed
Student
Unemployed
Other
Job Title:
Party Affiliation:
Democrat
Republican
Independent
Tea Party
Other
Unknown/Refused
Family Information:
Household Income:
under 15,000
15-19,999
20-29,999
30-39,999
40-49,999
50-59,999
60-69,999
70-79,999
80-89,999
90-99,999
100,000+
Unknown/refused
Marital Status:
Single
Married
Divorced/Separated
Widowed
Live With Other
Child 1:
Gender
Date of Birth
Male
Female
Month
January
February
March
April
May
June
July
August
September
October
November
December
Day
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
Year
1989
1990
1991
1992
1993
1994
1995
1996
1997
1998
1999
2000
2001
2002
2003
2004
2005
2006
2007
2008
2009
2010
2011
2012
2013
2014
2015
2016
2017
2018
2019
2020
Child 2:
Gender
Date of Birth
Male
Female
Month
January
February
March
April
May
June
July
August
September
October
November
December
Day
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
Year
1989
1990
1991
1992
1993
1994
1995
1996
1997
1998
1999
2000
2001
2002
2003
2004
2005
2006
2007
2008
2009
2010
2011
2012
2013
2014
2015
2016
2017
2018
2019
2020
Child 3:
Gender
Date of Birth
Male
Female
Month
January
February
March
April
May
June
July
August
September
October
November
December
Day
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
Year
1989
1990
1991
1992
1993
1994
1995
1996
1997
1998
1999
2000
2001
2002
2003
2004
2005
2006
2007
2008
2009
2010
2011
2012
2013
2014
2015
2016
2017
2018
2019
2020
Child 4:
Gender
Date of Birth
Male
Female
Month
January
February
March
April
May
June
July
August
September
October
November
December
Day
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
Year
1989
1990
1991
1992
1993
1994
1995
1996
1997
1998
1999
2000
2001
2002
2003
2004
2005
2006
2007
2008
2009
2010
2011
2012
2013
2014
2015
2016
2017
2018
2019
2020
Housing Type:
Apartment
College Dorm
Condominimum
House
Live w/ Parents
Mobile Home
Own
Rent
Unknown/Refused
Other
Other Information:
Do you use tobacco products?
Select all that apply.
(Hold down the <Ctrl>key while
clicking to make multiple selections)
No Tabacco Use
Cigarette-Menthol
Cigarette-NonMenthol/Reg
Cigarette-Light
Cigarette-Nonspecific
Cigars
Moist Snuff Tobacco
Timberwolf
Skoal
Grizzly
Longhorn
Kodiak
Copenhagen
Red Seal
Pouches
Long Cut
Fine Cut
Original/Regular/Natural
Straight
Wintergreen
Mint
Fruit Flavor
Other
Do you drink alcoholic beverages?
No
Yes
Do you have any pets?
Select all that apply.
(Hold down the <Ctrl> key while
clicking to make multiple selections)
No Pets
Bird
Cat
Dog
Fish - Freshwater
Fish - Saltwater
Reptile
Other
Chronic health conditions:
Select up to 3.
(Hold down the <Ctrl> key while
clicking to make multiple selections)
No Chronic Health Conditions
Allergies Food
Allergies Sinus
Arthritis
Arthritis - Rheumotoid
Cancer
Cancer Survivor
Diabetes-Type 1
Diabetes-Type 2
Dialysis
Headaches/Migraine
Heart Problems
High Blood Pressure
IBS-Irritable Bowel Syndrome
Mental Health Condition
Thyroid