HEALTH AND WELLNESS FAIR REGISTRATION

Disclaimer: Information being collected is required from the State to provide data on demographics being served in Green Lake County.

Name(Required)

First Last

Gender(Required)

Male

Female

Prefer not to say

Address(Required)

Street Address Address Line 2 City State ZIP Code

Phone(Required)

Married(Required)

Yes

No

If single, is your income below $1250 a month?(Required)

Yes

No

If there are 2 people in your household, is your income $1643 or more per month?

Yes

No

Date of Birth(Required)

MM slash DD slash YYYY

Do you live alone?

Yes

No

Race

Hispanic or Latino?

Yes

No