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* 1. Your First and Last Name:

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* 2. Email Address:

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* 3. School/Organization Name:

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* 4. Address:

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* 5. City:

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* 6. State

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* 7. Zip Code

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* 8. Cell Phone Number:

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* 9. In what county is your school located?

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* 10. What grade(s) do you teach?

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* 11. Please select the JA Elementary School Program you would like to receive:

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* 12. Number of Elementary Students

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* 13. Please select the JA Middle School Programs you would like to receive:

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* 14. Number of Middle School Students

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* 15. Please select the JA High School Programs you would like to receive:

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* 16. Number of High School Students

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* 17. What type of web-conferencing system do you use to communicate with your students? (Please specify all that apply)

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