1.What is your name? (first & last)

2.What is your email address?

3.What is the ZIP code where you live?

4.What is your gender identity?

Male

Female

Gender non-conforming

Prefer not to share

Other (please specify)

5.With which racial/ethnic heritage(s) do you identify? Please check all that apply.

Black or African-American

Hispanic or Latino

American Indian or Alaskan Native

East Asian

South Asian

Middle Eastern

Caucasian or White

Prefer not to share

Other (please specify)