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1
. Contact Name:
Contact Name:
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2
. Telephone #:
Telephone #:
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3
. E-mail Address:
E-mail Address:
*
4
. Organization(s) you are representing?
(If not applicable, please enter N/A)
Organization(s) you are representing? (If not applicable, please enter N/A)
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5
. May we contact you for more information about your story?
May we contact you for more information about your story?
Yes
No
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6
. Can we use your name when sharing your story or would you prefer to stay anonymous?
(Please note: Contact information will NOT be shared.)
Can we use your name when sharing your story or would you prefer to stay anonymous? (Please note: Contact information will NOT be shared.)
Yes! Please use my name when sharing my kindness story!
No, I wish to remain anonymous.
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7
. Your Kindness Story...
Your Kindness Story...
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8
. Would you like to receive electronic updates about Random Act of Kindness Day?
Would you like to receive electronic updates about Random Act of Kindness Day?
Yes
No
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