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Give 5 Demographic Survey & Media Release

  1. Give5

  2. 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.

  3. Gender*

  4. Which category includes your age?*

  5. How long have you lived at your current residence?*

  6. How long have you lived in Springfield/Greene County?How long have you lived in Springfield/Greene County?*

  7. What is the highest level of school you have completed or the highest degree you have received?*

  8. Which of the following categories best describes your employment status?*

  9. Which of the following best describes your most recent occupation?*

  10. How much total combined income did all of the members of your household earn last year?*

  11. At the year of your highest earnings, how much total combined income did all of the members of your household earn?*

  12. What is your racial or ethnic classification? Check more than one if applicable.*

  13. Are your living quarters owned or being bought by you or someone in your household, rented or occupied without payment of cash rent?*

  14. Which of the following best describes your relationship status?*

  15. How many children age 17 or younger live in your household?*

  16. Have you ever volunteered your time for a cause that you are passionate about? *

  17. How much of an impact do you feel your volunteer work had?*

  18. Did the organization offer volunteer training sessions? *

  19. How effective were the training sessions?*

  20. How easy was it to get along with the other volunteers at the organization?*

  21. How friendly was the staff at the organization?*

  22. How appreciated were you made to feel?*

  23. Overall, were you satisfied with your volunteer experience?*

  24. Photo/Video Release Authorization (please check one)

  25. 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.

  26. 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.

  27. Emergency Contacts

  28. Leave This Blank:

  29. This field is not part of the form submission.