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* 1. Name

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* 2. Church/Agency Name

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

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* 4. What is your street address?

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* 5. What is the Best phone number to contact you?

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* 6. Briefly describe why you want to participate in this pilot.

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* 7. Briefly describe the group you wish to pilot the study with.

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