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* 1. Contact Information

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* 2. What is your date of birth? (m/d/y)

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* 3. What is your pronoun preference?

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* 4. Please describe yourself in 140 characters... (like a tweet)

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* 5. Briefly describe if you are from of an underserved population (Lesbian, Gay, Bisexual, Transgender, person of color, low-income, etc)

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* 6. Briefly describe why you are interested in being involved in the Summit planning process.

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* 7. What youth programs are you currently involved in?

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* 8. Briefly describe your interest and/or experience in tobacco control and LGBT Health Equity.

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* 9. Are you planning on attending the Health Equity Summit on August 14th, 2012?

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* 10. Are you planning on attending the National Conference on Tobacco or Health,  August 15-17, 2012?

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* 11. Will another organization be paying for your travel to attend the National Conference on tobacco or Health?

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* 12. If another organization cannot support your travel, will you be applying for a scholarship from the Network to attend The Summit?

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