CORE Mirror
Enrollment Date
*
Participant Name
*
Participant Name
First Name
First Name
Last Name
Last Name
Name Suffix
Jr
Sr
I
II
III
Preferred Name
Email
*
Zip code
*
Birthdate
*
Gender
*
Male
Female
Non-binary
Prefer Not To Answer
Transgender
*
Yes
No
Prefer not to say
Unknown
Sexual Orientation
*
Asexual
Gay or lesbian
Pansexual or bisexual
Queer
Straight or heterosexual
Questioning or unsure
Self-describes in another way
Prefer not to say
Unknown
Sexual Orientation Detail
Race/Ethnicity
*
American Indian or Alaska Native
Asian
Black or African American
Hispanic or Latino (Ethnicity)
Middle Eastern or North African (MENA)
Native Hawaiian or Pacific Islander
White
Other
Other
Select All That Apply
Preferred Language
*
English
American Sign Language
Amharic
Arabic
Chinese—Cantonese
Chinese—Mandarin
Dari
Japanese
Khmer
Korean
Marshallese
Punjabi
Russian
Somali
Spanish
Tigrinya
Ukrainian
Vietnamese
Other (specify Language
Detail)
Prefer not to say
Unknown
Disability
*
Yes
No
Prefer not to say
Unknown
Experiencing Homelessness
*
Yes
No
Prefer not to say
Unknown
Completion
Yes
No
Not Applicable
Unknown
Have you gained Knowledge Skills
Yes
No
Not Applicable
Unknown
Have you experienced increased social or family connection
Yes
No
Not Applicable
Unknown
Do you feel Better about Youself
Yes
No
Not Applicable
Unknown
Has Your health and well-being improved
Yes
No
Not Applicable
Unknown
Exit Date
Submit Registration
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