1.      Are you 21 years of age or older?

Select one:

Yes
No


2.      Are you currently pregnant?

Select one:

Yes - First Trimester
Yes - Second Trimester
Yes - Third Trimester
No


3.      Have you resided in Pinellas, Pasco, Hillsborough, or Manatee Counties for at Least 1 Year?

Select one:

Yes
No


4.      Do You Have Minor Children that Reside With You?

Select one:

Yes
No



Submit All & Finish