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Relationship Assessment
1.
*
1
. Please enter your email address:
Please enter your email address:
(i.e. username@xyz.com)
*
2
. Wedding / Anniversary Date
MM
DD
YYYY
(if applicable):
Wedding / Anniversary Date (if applicable): Month
/
Day
/
Year
*
3
. How did you hear about ConnectEd PAIRS?
select...
Pick one of the options
Radio
TV
Internet
Friend
ConnectED PAIRS participant
Yellow Pages
Springfield MOMS
Other
How did you hear about ConnectEd PAIRS? Pick one of the options select...
Other (please specify)
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