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* 1. What types of preventive care and referral services would you be most interested in? (Check all that apply)

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* 2. How would you most prefer to access these wellness services? (Select one only)

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* 3. What days and times are most convenient for you to attend wellness activities? (Please rank in order of preference, 1 being most preferred and 4 being least preferred)

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* 4. What age group do you fall into?

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* 5. What is your name? (for the raffle)

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* 6. What is your phone number? (for the raffle)

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