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* 1. City

Name

School / Org

Address

Address 2

City/Town

State/Province

ZIP/Postal Code

Country

Email Address

Phone Number

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* 2. Size of Participating Student Group / Headcount

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* 3. Grade Levels

5th

6th

7th

8th

9th

10th

11th

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* 4. Which substance abuse issues are most likely in your student population?

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* 5. Why do you believe your school/org is best suited to participate in this study/besta-test?