Register to Join ANR’s Participant Database This registration form is for adults in the Richmond, Virginia and surrounding areas ONLY. All others will be discarded. Focus Group If you are a human and are seeing this field, please leave it blank. Fields marked with a * are required Status * New Entry Update Gender * MaleFemale First Name * Last Name * Street Address * Please spell out street types (i.e., Court instead of Ct.) City * County * -- Select -- Albermarle Amelia Charles City Chesapeake Chesterfield City of Richmond Colonial Heights Cumberland Dinwiddie Goochland Hanover Henrico King William Louisa Lunenburg Mecklenburg Middlesex New Kent Petersburg Powhatan Prince Edward Prince George York Are you a Virginia resident? * Yes No Zip / Post Code * Evening Phone Number * Daytime Phone Number Extension Cell Phone Number Email Address * Birthday (MM/DD/YYYY) * Marital Status * MarriedSingleDivorcedWidowed Education Less than high school graduateHigh school graduateSome college or technical schoolCollege graduatePost graduate studies or degree Hispanic Background * YesNo Race * African-American/BlackAsian-AmericanCaucasian/WhiteHispanicNative AmericanOther Household Income Under $20,000$20,000 - $29,999$30,000 - $39,999$40,000 - $49,999$50,000 - $74,999$75,000 - $99,000$100,000 - $149,000$150,000 - $174,000$175,000 or greater Employment Status Full-TimePart-TimeBusiness OwnerUnemployedStudent Occupation Are you a business owner? Yes No Have you ever served in the military? * YesNo Do you have children under 18 years old? YesNo Child 1 Birth Year Child 2 Birth Year Child 3 Birth Year Child 4 Birth Year Own or Rent Own Rent Not applicable Referral Source Friend/family Organization Facebook Web Search Print Ad Other Friend/Family Name Organization Name Other Referral If you are a human and are seeing this field, please leave it blank.