Update Demographics – Current Students

Please complete the follow details to update your membership. All information is confidential for internal use only. If you are not certain or not comfortable completing any section feel free to leave it blank.

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Name:

Date of Birth: (YYYY-MM-DD)

Gender:

Preferred Pronouns:

Race:

Ethnicity

Do any of the following apply to you? (you do not need to provide further information at this time)

Full-time Student

Retiree

Social Security Beneficiary (eg: disability)

Other Details (use this section to clarify any information provided or make any another comments):