Data Collection Form Head of household * First Name Last Name Neighborhood * Hays Blvd Masterson Station Polo Club Shoreside Ashby Glen Nicholasville Hamburg/Liberty Georgetown Richmond Leestown Cobb Lake StonyBrook Raintree Euclid Palumbo Drive/Valley/Steeplechase Other Household Type * Home Apartment Address (Optional) Address 1 Address 2 City State/Province Zip/Postal Code Country Contact Information Phone (###) ### #### Email * Household Information Family Size * Family Members (one family member per line) * Please use the following format when entering names: First Name, Last Name, Gender, Age Checkbox * By signing below I acknowledge that I have disclosed all of my personal information voluntarily and knowingly for the organization's (ANKA) information purposes only. ANKA is strictly prohibited to share any of the data I have provided with third parties. Violation will be subject to legal action. Thank you!
