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Registrant Name
First Name
Middle Name
Last Name
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
E-mail
example@example.com
Preferred Phone Number
"What is your age?"(Optional – for demographic purposes only)
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Under 18
18–24
25–34
35–44
45–54
55–64
65–74
75 or older
Prefer not to say
Please Share your Level of Education
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No High School Diploma
High School Graduate / GED
Trade / Specialized Certification
Some College
Bachelors
Masters
PHD
Other
"What is your gender?"(Optional – for demographic understanding only)
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Woman
Man
Non-binary
Transgender woman
Transgender man
Gender non-conforming
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What is your national origin or cultural heritage?"(Optional – for demographic understanding only)
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African (specify country)
Arab (specify country)
Caribbean (specify country)
Central American (specify country)
East Asian (e.g., Chinese, Japanese, Korean)
European (e.g., Italian, German, British)
Indigenous/Native (specify tribe or nation)
Latino/Hispanic (specify country)
Middle Eastern (specify country)
Pacific Islander (e.g., Hawaiian, Samoan)
South Asian (e.g., Indian, Pakistani, Bangladeshi)
Southeast Asian (e.g., Filipino, Vietnamese, Thai)
North American (e.g., U.S., Canadian)
Prefer not to answer
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