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* 1. In what city do you live?

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* 2. At what email address would you like to be contacted?

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* 3. Which race/ethnicity best describes you? (Please choose only one.)

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* 4. What is your approximate average household income?

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* 5. Which do you believe more money should be dedicated to?

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* 6. Does anyone in your household currently receive Medicaid benefits, or not?

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* 7. Please Rank from Your Child's Needs from 1-6 (1-most important 6-least important)

  Housing Medical/Treatment Educational Services Employment Respite Services Financial Assistance
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