Thank you for completing the Give 5 demographic survey and media release. This will provide us with valuable information from which to build current and future program days.Name* First Last Email* Class Number Gender* Male Female Other Which category includes your age?* 50-54 55-59 60-64 65-69 70-75 75+ How long have you lived in Springfield/Greene County?How long have you lived in Springfield/Greene County?* 0-9 years 10-19 years 20-29 years 30+ years What is the highest level of school you have completed or the highest degree you have received?* Less than high school degree High school degree or equivalent (e.g. GED) Trade /technical / vocational certification Associate degree Bachelor degree Graduate degree Which of the following categories best describes your employment status?* Employed, working 40 hours or more per week Employed, working 1-39 hours per week Not employed, looking for work Not employed, NOT looking for work Retired Disabled, not able to work Which of the following best describes your most recent occupation?* Construction Community and Social Service Building and Grounds Cleaning and Maintenance Management Arts, Design, Entertainment, Sports and Media Healthcare Support Healthcare Practitioners Installation, Maintenance and Repair Business and Financial Services Computer and Mathematical Legal Farming, Fishing and Forestry Production Operations Food Preparations and Serving-Related Protective Services Sales and Related Office and Administrative Support Personal Care and Service Architecture and Engineering Life, Physical and Social Science Transportation and Material Moving Homemaker Other How long have you lived at your current residence? How much total combined income did all of the members of your household earn last year?* $0- $9,9999 $10,000 - $24,999 $25,000 - $49,000 $50,000 - $74,999 $75,000 - $99,999 $100,000 - $124,999 $125,000 - $149,000 $150,000 - $174,999 $175,000 - $199,999 200,000 and above Prefer not to answer At the year of your highest earnings, how much total combined income did all of the members of your household earn?* $0- $9,9999 $10,000 - $24,999 $25,000 - $49,000 $50,000 - $74,999 $75,000 - $99,999 $100,000 - $124,999 $125,000 - $149,000 $150,000 - $174,999 $175,000 - $199,999 $200,000 and above Prefer not to answer What is your racial or ethnic classification? Check more than one if applicable.* White: A person having origins in any of the original peoples of Europe, the Middle East, or North Africa. Black or African-American: A person having origins in any of the black racial groups of Africa Native Hawaiian or Other Pacific Islander: A person having origins in any of the peoples of Hawaii, Guam, Samoa, or other Pacific Islands. Hispanic or Latino: A person of Cuban, Mexican, Puerto Rican, South or Central American, or other Spanish culture or origin, regardless of race. Asian: A person having origins in any of the original peoples of the Far East, Southeast Asia, or the Indian Subcontinent, including (for example) Cambodia, China, India, Japan, Korea, Malaysia, Paki American Indian or Alaska Native: A person having origins in any of the original peoples of North America and South America (including Central America), and who maintain tribal affiliation. Prefer not to answer. Which of the following best describes your relationship status?* Single Married Widowed Divorced Separated In a domestic partnership or civil union Single, but cohabitating with another person Single, never married How many children age 17 or younger live in your household?* None 1 2 3 4 More than 4 Have you ever volunteered your time for a cause that you are passionate about?* Yes No If yes, with what organization? How much of an impact do you feel your volunteer work had? Did the organization offer volunteer training sessions?YesNoHow effective were the training sessions? How easy was it to get along with the other volunteers at the organization? How friendly was the staff at the organization? How appreciated were you made to feel? Overall, were you satisfied with your volunteer experience? In a typical month, how many hours do you volunteer? To what extent do you agree with the following statements? Scale: 1 = Disagree strongly; 2 = Disagree a little; 3 = Neither agree or disagree; 4 = Agree a little; 5 = Agree stronglyI see myself as someone who is reserved. 1 (Disagree strongly) 2 (Disagree a little) 3 (Neither agree or disagree) 4 (Agree a little) 5 (Agree strongly) I see myself as someone who tends to be lazy. 1 (Disagree strongly) 2 (Disagree a little) 3 (Neither agree or disagree) 4 (Agree a little) 5 (Agree strongly) I see myself as someone who is relaxed, handles stress well. 1 (Disagree strongly) 2 (Disagree a little) 3 (Neither agree or disagree) 4 (Agree a little) 5 (Agree strongly) I see myself as someone who has few artistic interests. 1 (Disagree strongly) 2 (Disagree a little) 3 (Neither agree or disagree) 4 (Agree a little) 5 (Agree strongly) I see myself as someone who tends to find fault with others. 1 (Disagree strongly) 2 (Disagree a little) 3 (Neither agree or disagree) 4 (Agree a little) 5 (Agree strongly) I see myself as someone who does a thorough job. 1 (Disagree strongly) 2 (Disagree a little) 3 (Neither agree or disagree) 4 (Agree a little) 5 (Agree strongly) I see myself as someone who gets nervous easily. 1 (Disagree strongly) 2 (Disagree a little) 3 (Neither agree or disagree) 4 (Agree a little) 5 (Agree strongly) I see myself as someone who has an active imagination. 1 (Disagree strongly) 2 (Disagree a little) 3 (Neither agree or disagree) 4 (Agree a little) 5 (Agree strongly) I see myself as someone who is generally trusting. 1 (Disagree strongly) 2 (Disagree a little) 3 (Neither agree or disagree) 4 (Agree a little) 5 (Agree strongly) Emergency Contact 001Name* First Last Relationship To You* Phone Number*Emergency Contact 002Name* First Last Relationship To You* Phone Number*Photo/Video Release Authorization (please check one)* Check box to indicate signature.I grant the Springfield, Missouri, Give 5 program and any other public or private agency authorized by the Give 5 program, permission to use photo and video images or written quotes about my experience in the program that were taken by staff or volunteers of the program, or by people associated with participating nonprofit organizations, while I participated in the program. Photo images, quotes or video may be used for display, distribution, publication, transmission, or other use that promotes the program or is related to the program, in perpetuity and without compensation. Check box to indicate signature. I understand that Give 5 is in part publicly funded and therefore its list of participants is subject to Missouri Sunshine Law, but I would prefer not to have photographic or video images taken of myself.
