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* 1. Teacher Name: 

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* 2. Teacher School:

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* 3. Teacher Email:

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* 4. Teacher Phone Number (Work):

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* 5. Teacher Phone Number (Cell):

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* 6. Number of students participating:

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* 7. Choose a date from the following options:

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* 8. Indicate a specific time for your session, between the hours of 1 - 4 pm. Don't Sugar Coat Diabetes presentation duration is between 1 - 1.5 hours.

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