Dane Dinners!
QUESTIONNAIRE
Please fill out this =
form in
its entirety. Your answers w=
ill be
kept strictly confidential and will ONLY be used for the purpose of insuri=
ng
diversity at each table.
Name:
__________________________________________________________________
=
; &=
nbsp;
Last &=
nbsp; &nb=
sp; =
; &=
nbsp; &nb=
sp; Fir=
st =
&n=
bsp; &nbs=
p; =
Mailing
address: _________________________________________________________
=
&n=
bsp; &nbs=
p; =
&n=
bsp; =
;
Street address
=
&n=
bsp;
_________________________________________________________
=
; &=
nbsp; &nb=
sp; =
;
City =
; &=
nbsp; &nb=
sp;
Zip Code
Phone
number: ______________________________________________________
=
; &=
nbsp; &nb=
sp; =
;
Home =
; &=
nbsp; &nb=
sp;
Work
Email
address:____________________@__________________________
Sex: Male ___ Female
___
Age: Under 18___ 18-29___<=
span
style=3D'mso-spacerun:yes'> 30-44___<=
span
style=3D'mso-spacerun:yes'> 45-64___<=
span
style=3D'mso-spacerun:yes'> 65 and ov=
er___
Race/Ethnicity:
American Indian ___ Asi=
an
___
Black___
Caucasian___
Hispanic/Latino___ Mul=
ti
racial___ <=
/span>Other (please specify) ________________
What
languages do you speak? ______________________________________
Do
you require any special accommodations? Yes ___=
No ___
=
If
yes, what accommodations do you need? ____________________________
Please
make a meal selection from the choices below:
=
Meat
_____
OR
=
=
Vegetarian
_____
Please
note that this dinner is for adults only.
If
someone else will be attending the dinner with you, please have them fill =
out
the same questions on the back side of this sheet
PARTNER’S
ANSWERS
Name:
___________________________________________________________
=
; &=
nbsp; &nb=
sp;
Last &=
nbsp; &nb=
sp; =
; &=
nbsp; First
Mailing
address: __________________________________________________
=
&n=
bsp; &nbs=
p; =
&n=
bsp; =
;
Street address
=
&n=
bsp;
___________________________________________________
=
; &=
nbsp; &nb=
sp; =
;
City &=
nbsp; &nb=
sp; =
;
Zip Code &nb=
sp; =
; &nbs=
p;
Phone
number: _______________________________________________
=
; &=
nbsp; &nb=
sp; =
;
Home &=
nbsp; &nb=
sp; =
; &=
nbsp; Work =
;
=
; &=
nbsp; &nb=
sp;
Email
address:____________________@__________________________
Sex: Male ___ Female __=
_
Age: Under 18_____ 18-29___ 30-44___<=
span
style=3D'mso-spacerun:yes'> 45-64____ 65 and over____=
Race/Ethnicity
American India____ Asian____= Black____ Caucasian_____<= o:p>
Hispanic/Latino___ Multi
racial_____
Other (please specify)__________
What
languages do you speak? ______________________________________
Do you require any spec=
ial
accommodations? Yes __=
_No ___
=
If
yes, what accommodations do you need? ____________________
Please
make a meal selection from the choices below:
=
Meat
_____ =
;
OR
= Vegetarian ____
&nb= sp;