• First Name *
• Last Name *
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• Residence County *
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• Residence State *
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• Age Range *
  Under 18 18-24 25-44 45-64 65 and over Prefer not to answer
• Gender *
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• Ethnicity: Are you Hispanic, Latino/a or of Spanish origin? *
  No Yes Prefer not to answer
• Race (select all that apply) *
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