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* 1. Training date:

Date / Time

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* 2. Trainer Name:

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* 3. First Name

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* 4. Last Name

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* 6. Home Zip Code

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* 7. Phone Number

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* 8. Email Address

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* 9. Age group

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* 10. Gender

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* 11. Race

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* 12. Do you consider yourself Hispanic/Latino?

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* 14. Why are you attending a REVIVE! training event?

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* 15. Are you willing to train others?

T