Name
*
First Name
Last Name
Email
*
Phone
(###)
###
####
Address
Address 1
Address 2
City
State/Province
Zip/Postal Code
Country
I understand that this focus group is only for people who live in Madison, WI. Therefore, the stipend will be mailed to the address I provided above.
*
Which session do you plan to attend?
*
Southwest Madison Focus Group: 11/4/25 from 6:00 - 7:00, virtual with ASL interpretation
Southeast Madison Focus Group: 11/7/25 from noon - 1:00, virtual with ASL interpretation
Southwest Madison Focus Group: 11/12/25 from 6:00 - 7:30, in-person with Spanish interpretation provided
What organization referred you to this focus group?
*
Do you require interpretation?
*
If you selected "yes, another language" above, please share it below
What is your date of birth?
MM
DD
YYYY
What is your gender?
What is your racial and/or ethnic identity?
Please select all options that apply to you.
