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* 1. Are you a resident within the Jordan School District boundaries?

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* 2. What Interests You in the Coalition?

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* 3. What is your name?

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* 4. What is your street address?

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* 5. What is your ZipCode?

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* 6. At what email address would you like to be contacted?

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* 7. What is your telephone number?

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* 8. How familiar are you with Jordan District Wellness Coalition mission?

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* 9. Are you willing to attend monthly meetings and scheduled events?

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* 10. Do you have any other comments, questions, or concerns?

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