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* 1. I acknowledge that completing this form does not necessarily guarantee service.

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* 2. I acknowledge and agree that by submitting this form I am agreeing to share my delivery information with Big Brothers Big Sisters for the sole purpose of delivering my device.

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* 3. If you are not a family who is currently involved with Big Brothers Big Sisters Lacombe and District, what school division do your children attend?

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* 4. Main contact name.

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* 5. Name and age of Child in need of device.

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* 6. Contact phone number.

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* 7. Home Address

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