MISS Demographics Questionnaire

We need your help! MISS is currently seeking funds through various sources, and we are often asked general questions about the populations we serve. The questions below are optional; answer those that suit your comfort level. All answers will be kept strictly confidential. Completed questionnaires will be accepted until November 15, 2006. Please send to: 

by email:	info@missfoundation.org
by fax:		623-979-1001
by mail:	PO Box 5333
		Peoria, AZ  85385


Contact Information 

Name
Address
Phone Number
Email address
Employed by 

Child/Children's Full Name(s)
Date(s) of Birth
Date(s) of Death
Cause(s) of Death


Siblings/Subsequent Children - Please list the names and ages of all living children.



Please check

* single
* married
* divorced
* widowed


Education - please check highest level completed

* grade school
* high school
* some college
* college graduate
* graduate degree
* post graduate degree


Household Income 

* $0-$20,000
* $21,000-$40,000
* $41,000-$60,000
* $61,000-$80,000
* $81,000-$100,000
* $101,000+

Ethnicity

* Caucasian
* African-American
* Native American
* Hispanic/Latino
* Pacific Islander
* Asian
* Other


What is your religious background? 


Do you feel you have received sufficient support from the community in which you live?		Y  	N
Do you feel you have received sufficient support from your family?   				Y	N
Do you feel you have received sufficient support from the MISS Foundation?  			Y  	N


Please check if you are interested in 

* serving as a volunteer 
* serving on one of our boards

Contact information if different from that listed above: